43D2292092 CLIA NUMBER - TRI STATE MEDICAL CENTER PLLC

Laboratory Demographics

  • CLIA Code: 43D2292092
  • Facility Name: TRI STATE MEDICAL CENTER PLLC
  • Facility Address: 2398 5TH AVE SUITE 101
    BELLE FOURCHE, SD
    ZIP 57717
  • Facility Phone: 605 568-0191
  • Facility Type: Practitioner Other
  • Facility Type: Waiver
  • Lab Director: VANESSA KUDLOCK
  • NPI Number: 1073390944
  • Taxonomy: 363L00000X - Nurse Practitioner

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CLIA Record

Field Name Field Value
CLIA Number 43D2292092
LAB Type Practitioner Other
Facility Name TRI STATE MEDICAL CENTER PLLC
Street 2398 5TH AVE SUITE 101
City BELLE FOURCHE
State SD
ZIP 57717
Phone 605 568-0191
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 10/19/2023
Certificate Expiration Date 10/18/2025
Facility Type Practitioner Other
Lab Director VANESSA KUDLOCK

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This page was last updated on: 9/29/2025