Provider Demographics
NPI:1811527138
Name:TRI-COUNTY COMMUNITY CLINIC, LLC
Entity type:Organization
Organization Name:TRI-COUNTY COMMUNITY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LADONNA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, PMHNP-BC, FNP-C
Authorized Official - Phone:573-521-8530
Mailing Address - Street 1:46 E STATE HIGHWAY 162
Mailing Address - Street 2:
Mailing Address - City:PORTAGEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63873-9177
Mailing Address - Country:US
Mailing Address - Phone:573-391-8031
Mailing Address - Fax:573-391-8050
Practice Address - Street 1:46 E STATE HIGHWAY 162
Practice Address - Street 2:
Practice Address - City:PORTAGEVILLE
Practice Address - State:MO
Practice Address - Zip Code:63873-9177
Practice Address - Country:US
Practice Address - Phone:573-379-8031
Practice Address - Fax:573-391-8050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-26
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1861826968Medicaid