Provider Demographics
NPI:1073390944
Name:TRI STATE MEDICAL CENTER PLLC
Entity Type:Organization
Organization Name:TRI STATE MEDICAL CENTER PLLC
Other - Org Name:TRI STATE MEDICAL CENTER PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:KUDLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:605-568-0191
Mailing Address - Street 1:2398 5TH AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:BELLE FOURCHE
Mailing Address - State:SD
Mailing Address - Zip Code:57717-2340
Mailing Address - Country:US
Mailing Address - Phone:605-645-2064
Mailing Address - Fax:
Practice Address - Street 1:2398 5TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:BELLE FOURCHE
Practice Address - State:SD
Practice Address - Zip Code:57717-2340
Practice Address - Country:US
Practice Address - Phone:605-645-2064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-13
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner