Healthcare Provider Details

I. General information

NPI: 1124097795
Provider Name (Legal Business Name): TRI STATE CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 03/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 SLATE CREEK RD
GRUNDY VA
24614-6975
US

IV. Provider business mailing address

1520 SLATE CREEK RD
GRUNDY VA
24614-6975
US

V. Phone/Fax

Practice location:
  • Phone: 276-935-8620
  • Fax: 276-935-4430
Mailing address:
  • Phone: 276-935-8620
  • Fax: 276-935-4430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. JANET STACY
Title or Position: ADMINISTRATOR
Credential:
Phone: 276-935-8620