Basic Information
| Provider Information | |||||||||
| NPI: | 1922356369 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRI-STATE COMMUNITY HEALTHCARE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1402 BAILEY AVE | ||||||||
| Address2: | |||||||||
| City: | NEEDLES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923633104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603260222 | ||||||||
| FaxNumber: | 7603260221 | ||||||||
| Practice Location | |||||||||
| Address1: | 1402 BAILEY AVE | ||||||||
| Address2: | |||||||||
| City: | NEEDLES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923633104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603260222 | ||||||||
| FaxNumber: | 7603260221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2012 | ||||||||
| LastUpdateDate: | 03/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | MANOUKIAN | ||||||||
| AuthorizedOfficialFirstName: | ARAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8186526612 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QP2300X | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.