Provider Demographics
NPI:1952678658
Name:TRI STAR LLC.
Entity Type:Organization
Organization Name:TRI STAR LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SPAULDING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-283-9441
Mailing Address - Street 1:648 E MONMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-3227
Mailing Address - Country:US
Mailing Address - Phone:336-283-9441
Mailing Address - Fax:
Practice Address - Street 1:648 EAST MONMOUTH STREET
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-3227
Practice Address - Country:US
Practice Address - Phone:336-283-9441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC034290251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC=========Medicaid