Healthcare Provider Details

I. General information

NPI: 1568622868
Provider Name (Legal Business Name): TRISTATE RURAL HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2008
Last Update Date: 06/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20757 RIVERSIDE DR
GRUNDY VA
24614-6746
US

IV. Provider business mailing address

20757 RIVERSIDE DR
GRUNDY VA
24614-6746
US

V. Phone/Fax

Practice location:
  • Phone: 276-935-6424
  • Fax: 276-935-2494
Mailing address:
  • Phone: 276-935-6055
  • Fax: 276-935-4430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number0101031664
License Number StateVA

VIII. Authorized Official

Name: MRS. JANET STACY
Title or Position: OFFICE MANAGER
Credential:
Phone: 276-935-6044