Provider Demographics
NPI:1033587308
Name:TRISTATE AMBULATORY SURGERY CENTER
Entity Type:Organization
Organization Name:TRISTATE AMBULATORY SURGERY CENTER
Other - Org Name:COLORADO RIVER MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:KELLEY
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-326-7160
Mailing Address - Street 1:1401 BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:NEEDLES
Mailing Address - State:CA
Mailing Address - Zip Code:92363-3103
Mailing Address - Country:US
Mailing Address - Phone:760-326-7160
Mailing Address - Fax:760-326-7292
Practice Address - Street 1:1401 BAILEY AVE
Practice Address - Street 2:BUILDING A
Practice Address - City:NEEDLES
Practice Address - State:CA
Practice Address - Zip Code:92363-3103
Practice Address - Country:US
Practice Address - Phone:760-326-7160
Practice Address - Fax:760-326-7292
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY HEALTHCARE PARTNER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA1903X
CA240000227282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA240000227Medicaid
AZ330130Medicaid
AZ053123Medicare Oscar/Certification