Basic Information
| Provider Information | |||||||||
| NPI: | 1336646397 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRI-STATE COMMUNITY HEALTHCARE CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MOBILE CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1402 BAILEY AVE | ||||||||
| Address2: | |||||||||
| City: | NEEDLES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923633104 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11888 BARTLETT AVE | ||||||||
| Address2: | |||||||||
| City: | ADELANTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923011709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603260222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2018 | ||||||||
| LastUpdateDate: | 04/06/2018 | ||||||||
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| AuthorizedOfficialLastName: | MANOUKIAN | ||||||||
| AuthorizedOfficialFirstName: | ARAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7603260222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRI-STATE COMMUNITY HEALTHCARE CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.