Provider Demographics
NPI:1336646397
Name:TRI-STATE COMMUNITY HEALTHCARE CENTER
Entity Type:Organization
Organization Name:TRI-STATE COMMUNITY HEALTHCARE CENTER
Other - Org Name:MOBILE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ARAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MANOUKIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-326-0222
Mailing Address - Street 1:1402 BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:NEEDLES
Mailing Address - State:CA
Mailing Address - Zip Code:92363-3104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11888 BARTLETT AVE
Practice Address - Street 2:
Practice Address - City:ADELANTO
Practice Address - State:CA
Practice Address - Zip Code:92301-1709
Practice Address - Country:US
Practice Address - Phone:760-326-0222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI-STATE COMMUNITY HEALTHCARE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)