Provider Demographics
NPI:1518264829
Name:TRI-STATE RADIATION ONCOLOGY, INC.
Entity Type:Organization
Organization Name:TRI-STATE RADIATION ONCOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:JUNE
Authorized Official - Last Name:RYDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-763-3600
Mailing Address - Street 1:2755 SILVER CREEK RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-7904
Mailing Address - Country:US
Mailing Address - Phone:928-763-3600
Mailing Address - Fax:928-763-5700
Practice Address - Street 1:2755 SILVER CREEK RD
Practice Address - Street 2:SUITE 115
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7904
Practice Address - Country:US
Practice Address - Phone:928-763-3600
Practice Address - Fax:928-763-5700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-22
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8-M-6352261QX0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation