Healthcare Provider Details

I. General information

NPI: 1366491201
Provider Name (Legal Business Name): TRI-STATE COMMUNITY HEALTH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 08/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 W HIGH ST
HANCOCK MD
21750-1143
US

IV. Provider business mailing address

109 RAYLOC DR
HANCOCK MD
21750-1518
US

V. Phone/Fax

Practice location:
  • Phone: 301-678-5187
  • Fax: 301-678-5797
Mailing address:
  • Phone: 301-678-5187
  • Fax: 301-678-5797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHEILA J DESHONG
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 301-678-7256