Healthcare Provider Details

I. General information

NPI: 1508379017
Provider Name (Legal Business Name): TRI-STATE COMMUNITY HEALTHCARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2017
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11499 BARTLETT AVE
ADELANTO CA
92301-1902
US

IV. Provider business mailing address

1535 E COLORADO ST
GLENDALE CA
91205-1513
US

V. Phone/Fax

Practice location:
  • Phone: 760-444-4258
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CRYSTALE MINEROS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 909-575-7161