MEDICARE: TRI-STATE MEDICAL SPECIALISTS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332900000X	Non-Pharmacy Dispensing Site

General Provider Information

NPI Number	:	1023302643
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI-STATE MEDICAL SPECIALISTS LLC

Provider Business Mailing Address
First Line	:	PO BOX 10966
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86427-0966
Country	:	US
Telephone Number	:	928-788-3333
Fax Number	:	928-788-3555

Provider Business Practice Location Address
First Line	:	1510 WAGON WHEEL LANE
Second Line	:	SUITE 110
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-6698
Country	:	US
Telephone Number	:	928-788-3333
Fax Number	:	928-788-3555

Authorized Official
Title or Position	:	OWNER
Name	:	JOANN VENGER
Credential	:
Telephone Number	:	928-788-3333

Provider Enumeration Date	:	05/31/2011
Last Update Date	:	07/19/2022

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