Healthcare Provider Details

I. General information

NPI: 1811464118
Provider Name (Legal Business Name): TRI-STATE MEDICAL SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9555 SOUTH EASTERN AVENUE STE. 210
HENDERSON NV
89121
US

IV. Provider business mailing address

PO BOX 10966
FORT MOHAVE AZ
86427-0966
US

V. Phone/Fax

Practice location:
  • Phone: 928-788-3333
  • Fax: 928-788-3555
Mailing address:
  • Phone: 928-788-3333
  • Fax: 928-788-3555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOANN VENGER
Title or Position: OWNER/MEMBER MANAGER
Credential:
Phone: 928-788-3333