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General NPI Number Information
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NPI Number | 1841984036
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Entity Type | Organization
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Legal Business Name | TRI-STATE HEALING INITIATIVE LLC
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Dates
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Enumeration Date | 06/08/2023
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Last Update Date | 06/17/2025
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Provider Practice Location Address
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Address Line | 1619 DIEDERICH BLVD STE D1
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City | RUSSELL
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State | KY
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Zip | 41169-1778
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Country | US
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Telephone | 952-261-7105
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Fax |
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Provider Business Mailing Address
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Address Line | 17 LACKAWANNA PL APT 318
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City | BLOOMFIELD
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State | NJ
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Zip | 07003-2954
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BRYCE RATLIFF
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Credential | MD
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Telephone | 952-261-7105
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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