Provider Demographics
NPI:1508379017
Name:TRI-STATE COMMUNITY HEALTHCARE CENTER
Entity Type:Organization
Organization Name:TRI-STATE COMMUNITY HEALTHCARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTALE
Authorized Official - Middle Name:
Authorized Official - Last Name:MINEROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-575-7161
Mailing Address - Street 1:1535 E COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11499 BARTLETT AVE
Practice Address - Street 2:
Practice Address - City:ADELANTO
Practice Address - State:CA
Practice Address - Zip Code:92301-1902
Practice Address - Country:US
Practice Address - Phone:760-444-4258
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI-STATE COMMUNITY HEALTHCARE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-07
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care