03D2004513 CLIA NUMBER - TRI-STATE MEDICAL SPECIALISTS, LLC DBA TRI-STATE PAIN INSTITUTE

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Laboratory Demographics

CLIA Number: 03D2004513

Facility Name: TRI-STATE MEDICAL SPECIALISTS, LLC DBA TRI-STATE PAIN INSTITUTE

Facility Address:
1510 WAGON WHEEL LANE, STE 110
FORT MOHAVE, AZ
ZIP 86426
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Facility Phone Number: 928 788-3333

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1518472950

Taxonomy: 261QR0200X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	03D2004513
LAB Type	Physician Office
Facility Name	TRI-STATE MEDICAL SPECIALISTS, LLC DBA TRI-STATE PAIN INSTITUTE
Street	1510 WAGON WHEEL LANE, STE 110
City	FORT MOHAVE
State	AZ
ZIP	86426
Phone	928 788-3333
CertificateType	4
CertificateEffectiveDate	9/24/2022
CertificateExpirationDate	9/23/2024
FacilityType	Waiver

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This page was last updated on: 4/23/2024