| NPI | 1073390944 |
|---|---|
| Former Legal Business Name | TRI STATE MEDICAL CENTER PLLC |
| Entity Type | Organization |
| Authorized Contact | VANESSA KUDLOCK Owner 605-568-0191 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner |
| Enumeration Date | 2023-09-13 |
| Last Update Date | 2024-01-11 |