Provider Demographics
NPI:1932649605
Name:TRI-STATE FAMILYCARE, INC
Entity Type:Organization
Organization Name:TRI-STATE FAMILYCARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROARL
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:606-242-3100
Mailing Address - Street 1:2317 CUMBERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-2834
Mailing Address - Country:US
Mailing Address - Phone:606-242-3100
Mailing Address - Fax:
Practice Address - Street 1:2317 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-2834
Practice Address - Country:US
Practice Address - Phone:606-242-3100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011074363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1437281649OtherNPI