Provider Demographics
NPI:1831100254
Name:TRI-STATE MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:TRI-STATE MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:C
Authorized Official - Last Name:TOWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-758-4667
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-0189
Mailing Address - Country:US
Mailing Address - Phone:509-758-5511
Mailing Address - Fax:509-751-9406
Practice Address - Street 1:1100 HIGHLAND AVENUE
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403
Practice Address - Country:US
Practice Address - Phone:509-758-2568
Practice Address - Fax:509-758-3413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIS457251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3990470Medicaid
WA3990470Medicaid