Provider Demographics
NPI:1568622868
Name:TRISTATE RURAL HEALTH CLINIC
Entity Type:Organization
Organization Name:TRISTATE RURAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE 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:276-935-6044
Mailing Address - Street 1:20757 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614-6746
Mailing Address - Country:US
Mailing Address - Phone:276-935-6055
Mailing Address - Fax:276-935-4430
Practice Address - Street 1:20757 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-6746
Practice Address - Country:US
Practice Address - Phone:276-935-6424
Practice Address - Fax:276-935-2494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101031664173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006091750Medicaid
VAC47391Medicare UPIN
VA006091750Medicaid