TRI STATE MEDICAL ALLIANCE LLC NPI 1518472950

NPI Information

NPI: 1518472950
Provider Name: TRI STATE MEDICAL ALLIANCE LLC
Classification: Clinic/Center - 261QR0200X
Entity Type: Organization

Specialization: Radiology

CLIA Number: 03D2004513

Address:
1510 E WAGON WHEEL LN STE 103
FORT MOHAVE, AZ
ZIP 86426
Phone: (928) 460-7226
Get Directions

TRI STATE MEDICAL ALLIANCE LLC is a radiology clinic center in Fort Mohave, AZ. TRI STATE MEDICAL ALLIANCE LLC NPI is 1518472950. The provider is registered as an organization entity type.

The provider's business location address is:

1510 E WAGON WHEEL LN STE 103
FORT MOHAVE, AZ
ZIP 86426-698
Phone: (928) 460-7226
Fax: (928) 447-6113

The provider's authorized official is Hanz Tabora .
The authorized official title is Owner/member Manager and has the following contact phone number (928) 460-7226.

The CLIA number assigned to this NPI record is 03D2004513 - physician office with a certificate type of Certificate of Waiver.

The enumeration date for this NPI number is 12/7/2017 and was last updated on 11/3/2023.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No.	Taxonomy Code	Taxonomy Clasification	Taxonomy Specialization	License Number	License State	Primary
1	293D00000X	Physiological Laboratory				No
2	261QR0200X	Clinic/Center	Radiology			Yes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No.	Other Provider Identifier	Other Provider Identifier Type	Other Provider Identifier State	Other Provider Identifier Issuer
1	L22382013	OTHER	ARIZONA	CORPORATION ID#
2	557885	MEDICAID	ARIZONA

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 4/28/2024

NPI Synchronization or Removal

All materials and services on this site are provided on an "as is" and "as available" basis without warranty of any kind. The NPI record is maintained by the National Plan & Provider Enumeration System (NPPES) and anyone may request this information and other NPPES health care provider data from HHS under The Freedom of Information Act (FOIA), Title 5 of the United States Code, section 552. To update the NPI records please contact the NPPES.

« Previous NPI

Next NPI »