MEDICARE: TRI STATE MEDICAL CENTER PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1073390944
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI STATE MEDICAL CENTER PLLC

Provider Business Mailing Address
First Line	:	2398 5TH AVE STE 101
Second Line	:
City	:	BELLE FOURCHE
State	:	SD
Zip	:	57717-2340
Country	:	US
Telephone Number	:	605-645-2064
Fax Number	:

Provider Business Practice Location Address
First Line	:	2398 5TH AVE STE 101
Second Line	:
City	:	BELLE FOURCHE
State	:	SD
Zip	:	57717-2340
Country	:	US
Telephone Number	:	605-645-2064
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	VANESSA KUDLOCK
Credential	:	CNP
Telephone Number	:	605-568-0191

Provider Enumeration Date	:	09/13/2023
Last Update Date	:	01/11/2024

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