Healthcare Provider Details

I. General information

NPI: 1932649605
Provider Name (Legal Business Name): TRI-STATE FAMILYCARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2017
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2317 CUMBERLAND AVE
MIDDLESBORO KY
40965-2834
US

IV. Provider business mailing address

2317 CUMBERLAND AVE
MIDDLESBORO KY
40965-2834
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3011074
License Number StateKY

VIII. Authorized Official

Name: LARRY ROARL
Title or Position: PRESIDENT/OWNER
Credential: APRN
Phone: 606-242-3100