Provider Demographics
NPI:1518083971
Name:TRI STATE CLINIC, INC.
Entity Type:Organization
Organization Name:TRI STATE CLINIC, INC.
Other - Org Name:TRI STATE RURAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:STACY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-935-6055
Mailing Address - Street 1:1520 SLATE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614-6975
Mailing Address - Country:US
Mailing Address - Phone:276-935-6055
Mailing Address - Fax:276-935-4430
Practice Address - Street 1:1520 SLATE CREEK RD
Practice Address - Street 2:
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-6975
Practice Address - Country:US
Practice Address - Phone:276-935-6055
Practice Address - Fax:276-935-4430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 208000000X
VA0110004247363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC08037Medicare PIN
VAC06780Medicare PIN