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General NPI Number Information
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NPI Number | 1932649605
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Entity Type | Organization
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Legal Business Name | TRI-STATE FAMILYCARE, INC
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Dates
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Enumeration Date | 03/01/2017
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Last Update Date | 03/01/2017
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Provider Practice Location Address
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Address Line | 2317 CUMBERLAND AVE
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City | MIDDLESBORO
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State | KY
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Zip | 40965-2834
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Country | US
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Telephone | 606-242-3100
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Fax |
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Provider Business Mailing Address
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Address Line | 2317 CUMBERLAND AVE
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City | MIDDLESBORO
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State | KY
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Zip | 40965-2834
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Country | US
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Telephone | 606-242-3100
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | LARRY ROARL
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Credential | APRN
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Telephone | 606-242-3100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 3011074
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License Number State | KY
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