Provider Demographics
NPI:1851523575
Name:TRI-STATE DOCTORS OF
Entity type:Organization
Organization Name:TRI-STATE DOCTORS OF
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBESH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:726-444-4078
Mailing Address - Street 1:PO BOX 846027
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6027
Mailing Address - Country:US
Mailing Address - Phone:210-340-3531
Mailing Address - Fax:
Practice Address - Street 1:13210 SHELBYVILLE RD STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-3981
Practice Address - Country:US
Practice Address - Phone:502-244-9198
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-13
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1240070028Medicare NSC