Provider Demographics
NPI:1558477257
Name:TRI-CARE, PA
Entity Type:Organization
Organization Name:TRI-CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:N
Authorized Official - Last Name:HARRISON-CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-659-8301
Mailing Address - Street 1:1702 S HAWTHORNE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4016
Mailing Address - Country:US
Mailing Address - Phone:336-659-8301
Mailing Address - Fax:336-659-9361
Practice Address - Street 1:1702 S HAWTHORNE RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4016
Practice Address - Country:US
Practice Address - Phone:336-659-8301
Practice Address - Fax:336-659-9361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0204WOtherBLUECROSSBLUESHIELDGRP#