Healthcare Provider Details

I. General information

NPI: 1518472950
Provider Name (Legal Business Name): TRI-STATE MEDICAL ALLIANCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2017
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 E WAGON WHEEL LN STE 103
FORT MOHAVE AZ
86426-6698
US

IV. Provider business mailing address

1510 E WAGON WHEEL LN STE 103
FORT MOHAVE AZ
86426-6698
US

V. Phone/Fax

Practice location:
  • Phone: 928-460-7226
  • Fax: 928-447-6113
Mailing address:
  • Phone: 928-460-7226
  • Fax: 928-447-6113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: BING LUM
Title or Position: MEMBER MANAGER
Credential:
Phone: 760-326-7162