Healthcare Provider Details

I. General information

NPI: 1780292839
Provider Name (Legal Business Name): TRI-STATE COMMUNITY HEALTHCARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11328 BARTLETT AVE STE 3
ADELANTO CA
92301-1913
US

IV. Provider business mailing address

11328 BARTLETT AVE STE 3
ADELANTO CA
92301-1913
US

V. Phone/Fax

Practice location:
  • Phone: 760-237-8848
  • Fax: 760-237-8847
Mailing address:
  • Phone: 760-530-9944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: CRYSTALE MINEROS
Title or Position: MANAGED CARE DIRECTOR
Credential:
Phone: 323-297-0884