Healthcare Provider Details

I. General information

NPI: 1649370719
Provider Name (Legal Business Name): TRI STATE MEDICAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 01/31/2020
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3503 CUMBERLAND AVE
MIDDLESBORO KY
40965-2611
US

IV. Provider business mailing address

PO BOX 217
MIDDLESBORO KY
40965-0217
US

V. Phone/Fax

Practice location:
  • Phone: 606-242-3100
  • Fax: 606-242-3984
Mailing address:
  • Phone: 606-242-3100
  • Fax: 606-242-3984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LARRY B ROARK
Title or Position: NURSE PRACTITIONER/OWNER
Credential: NP-C
Phone: 606-242-3100