| Tri-state Vascular Group, Pllc | |
|
1401 Bailey Ave Bldg A Needles CA 92363-3103 | |
| (960) 590-0155 | |
| (760) 326-7170 |
| Full Name | Tri-state Vascular Group, Pllc |
|---|---|
| Speciality | Surgery |
| Location | 1401 Bailey Ave Bldg A, Needles, California |
| Authorized Official Name and Position | Wantzy Cooper (OWNER/MEMBER MANAGER) |
| Authorized Official Contact | 7605900155 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Tri-state Vascular Group, Pllc Po Box 9893 Fort Mohave AZ 86427-9893 Ph: (928) 788-4944 | Tri-state Vascular Group, Pllc 1401 Bailey Ave Bldg A Needles CA 92363-3103 Ph: (960) 590-0155 |
| NPI Number | 1366993818 |
|---|---|
| Provider Enumeration Date | 10/19/2016 |
| Last Update Date | 04/08/2024 |
| Medicare PECOS PAC ID | 5395026827 |
|---|---|
| Medicare Enrollment ID | O20161221001174 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1366993818 | NPI | - | NPPES |
| P20421635 | Other | AZ | CORPORATION REGISTRATION NUMBER |
| 205332 | Medicaid | AZ |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 208D00000X | General Practice | (* (Not Available)) | Secondary |
| 2086S0129X | Surgery - Vascular Surgery | (* (Not Available)) | Primary |
| Provider Name | Wantzy Cooper |
|---|---|
| Provider Type | Practitioner - Vascular Surgery |
| Provider Identifiers | NPI Number: 1942383393 PECOS PAC ID: 6002815214 Enrollment ID: I20110208000789 |
Tri-state Community Healthcare Center Primary Care Clinic Medicare: Not Enrolled in Medicare Practice Location: 1402 Bailey Ave Ste A, Needles, CA 92363 Phone: 760-326-0222 | |
Tri-state Community Healthcare Center Primary Care Clinic Medicare: Medicare Enrolled Practice Location: 1402 Bailey Ave, Needles, CA 92363 Phone: 760-326-0222 Fax: 769-326-0221 |