Healthcare Provider Details

I. General information

NPI: 1508632605
Provider Name (Legal Business Name): TRISTAR HEALTH CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2023
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 VERNON ST STE 203
WORCESTER MA
01610-1989
US

IV. Provider business mailing address

95 VERNON ST STE 203
WORCESTER MA
01610-1989
US

V. Phone/Fax

Practice location:
  • Phone: 508-373-2041
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL NELSON
Title or Position: MANAGER
Credential:
Phone: 508-314-9896