NPIMap

Organization Active NPI

Tri State Clinic, Inc.

  • Rural Health Clinic/Center
  • Grundy, VA
National Provider Identifier
1124097795
Registry record updated Mar 9, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
TRI STATE CLINIC, INC.
Practice address
1520 Slate Creek Rd
Grundy, VA 24614-6975
Phone
(276) 935-8620
Fax
(276) 935-4430
NPI assigned
Mar 16, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 9, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Janet Stacy
Title
Administrator
Phone
(276) 935-8620

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

1520 Slate Creek Rd
Grundy, VA 24614-6975

Mailing address

1520 Slate Creek Rd
Grundy, VA 24614-6975
Phone (276) 935-8620

Other identifiers 3

IdentifierTypeStateIssuer
007610262MedicaidVA
35000470MedicaidKY
0034714000MedicaidWV

Other names 1

  • Tri State Rural Health Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080505000220 VA Part A Provider - Rural Health Clinic 6709850993 Practice locations: Grundy, VA

Rural health clinic certification: CCN 493829

Legal name
TRI STATE CLINIC, INC.
Doing business as
TRI STATE RURAL HEALTH CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Oct 4, 1995
Last certification
Jun 29, 2022
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
Feb 9, 1984 in VA
Enrollment address
1520 Slate Creek Rd
Grundy, VA 24614-6975

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Tri State Clinic3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1520 Slate Creek Rd
Ste 101
Grundy, VA 24614
Phone (276) 935-6476

1520 Slate Creek Rd
Ste 106
Grundy, VA 24614

Ownership & related parties

All disclosed owners & managing parties 4

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Haresh J Patel Individual 5% Or Greater Direct Ownership Interest Mar 25, 2011 25%
General Partnership Interest Mar 13, 2015
Operational/Managerial ControlOwner Mar 25, 2011 25%
Jashubhai G Patel Individual Operational/Managerial ControlOwner Mar 25, 2011 25%
Rajnikant Patel Individual 5% Or Greater Direct Ownership Interest Jan 1, 1986 25%
General Partnership Interest Jan 1, 1986
Operational/Managerial ControlOwner Jan 1, 2006 25%
Dinkar Nathabhia Patel Individual 5% Or Greater Direct Ownership Interest Jan 1, 1986 25%
General Partnership Interest Jan 7, 2008
Operational/Managerial ControlOwner/Director Jan 1, 2006 25%

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

  • Dinkar N Patel, M.D.
    • Internal Medicine Physician
    • Grundy, VA
    • NPI 1831168004

    5% Or Greater Direct Ownership Interest, General Partnership Interest, Operational/Managerial Control

    CMS ownership
  • Haresh J Patel, M.D.
    • Internal Medicine Physician
    • Grundy, VA
    • NPI 1245209402

    5% Or Greater Direct Ownership Interest, General Partnership Interest, Operational/Managerial Control

    CMS ownership
  • Jashubhai G Patel, MD
    • Internal Medicine Physician
    • Grundy, VA
    • NPI 1922049212

    Operational/Managerial Control

    CMS ownership

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1142467200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1268092800000",
    "number": "1124097795",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1520 SLATE CREEK RD",
            "city": "GRUNDY",
            "state": "VA",
            "postal_code": "246146975",
            "telephone_number": "276-935-8620",
            "fax_number": "276-935-4430"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1520 SLATE CREEK RD",
            "city": "GRUNDY",
            "state": "VA",
            "postal_code": "246146975",
            "telephone_number": "276-935-8620",
            "fax_number": "276-935-4430"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TRI STATE CLINIC, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-16",
        "last_updated": "2010-03-09",
        "status": "A",
        "authorized_official_last_name": "STACY",
        "authorized_official_first_name": "JANET",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "276-935-8620",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "007610262",
            "state": "VA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "35000470",
            "state": "KY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0034714000",
            "state": "WV"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Tri State Rural Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Grundy, VA

Sources for this page

Verify at the official NPI Registry.