| Organization Name: | TRI-STATE MEDICAL SPECIALISTS LLC |
| NPI Number: | 1023302643 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | BENJAMIN VENGER (OWNER) |
| Mailing Address: | 1510 Wagon Wheel Lane Suite 110 Fort Mohave |
| State: | AZ US |
| Postal Code: | 864266698 |
| Phone Number: | 9287883333 |
| Fax Number: | |
| NPI Enumeration Date: | 05/31/2011 |
| NPI Last Update Date: | 03/02/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332900000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Non-Pharmacy Dispensing Site |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A site other than a pharmacy that dispenses medicinal preparations under the supervision of a physician to patients for self-administration. (e.g. physician offices, ER, Urgent Care Centers, Rural Health Facilities, etc.) |