Provider Demographics
NPI:1083055081
Name:TRI-STATE COMMUNITY HEALTH CENTER, INC
Entity Type:Organization
Organization Name:TRI-STATE COMMUNITY HEALTH CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DESHONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-678-5187
Mailing Address - Street 1:109 RAYLOC DR
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MD
Mailing Address - Zip Code:21750-1518
Mailing Address - Country:US
Mailing Address - Phone:301-678-5187
Mailing Address - Fax:301-678-5797
Practice Address - Street 1:261 BERKMORE PL
Practice Address - Street 2:SUITE 1A
Practice Address - City:BERKELEY SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:25411-6247
Practice Address - Country:US
Practice Address - Phone:304-258-5790
Practice Address - Fax:304-258-3745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-08
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2291-3644261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
511021OtherFQHC