Provider Demographics
NPI:1417415530
Name:TRI-CITIES INFUSION AND WELLNESS CLINIC
Entity Type:Organization
Organization Name:TRI-CITIES INFUSION AND WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GOVENOR
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:THORNOCK
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:435-668-4334
Mailing Address - Street 1:15205 S MOUNTAIN RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99338-8325
Mailing Address - Country:US
Mailing Address - Phone:435-668-4334
Mailing Address - Fax:
Practice Address - Street 1:7211 W DESCHUTES AVE STE D202
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7715
Practice Address - Country:US
Practice Address - Phone:435-668-3443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-07
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty