Provider Demographics
NPI:1386690907
Name:TRI-STATE MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:TRI-STATE MEMORIAL HOSPITAL
Other - Org Name:TRI STATE DIALYSIS CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:C
Authorized Official - Last Name:TOWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-758-4667
Mailing Address - Street 1:1221 HIGHLAND AVE.
Mailing Address - Street 2:PO BOX 189
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:98940
Mailing Address - Country:US
Mailing Address - Phone:509-758-5511
Mailing Address - Fax:509-751-9406
Practice Address - Street 1:730 21ST ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-3323
Practice Address - Country:US
Practice Address - Phone:208-746-8280
Practice Address - Fax:208-746-8285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QE0700X
WAH-108261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003110900Medicaid
WA3308004Medicaid
WA3308004Medicaid
WA502310Medicare Oscar/Certification