Healthcare Provider Details

I. General information

NPI: 1366993818
Provider Name (Legal Business Name): TRI-STATE VASCULAR GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2016
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 BAILEY AVE BLDG A
NEEDLES CA
92363-3103
US

IV. Provider business mailing address

PO BOX 9893
FORT MOHAVE AZ
86427-9893
US

V. Phone/Fax

Practice location:
  • Phone: 960-590-0155
  • Fax: 760-326-7170
Mailing address:
  • Phone: 928-788-4944
  • Fax: 928-788-4949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: WANTZY COOPER
Title or Position: OWNER/MEMBER MANAGER
Credential: D.O.
Phone: 760-590-0155