Organization
TRI-STATE MEDICAL ALLIANCE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BING LUM (MEMBER MANAGER)
(760) 326-7162
Entity
Organization
Contact information
Practice address
1510 E WAGON WHEEL LN STE 103, FORT MOHAVE, AZ 86426-6698
(928) 460-7226
(928) 447-6113
Mailing address
1510 E WAGON WHEEL LN STE 103, FORT MOHAVE, AZ 86426-6698
(928) 460-7226
(928) 447-6113
Taxonomy
Speciality
Code
Description
License number
State
261QR0200X
Radiology Clinic/Center
Primary
—
—
293D00000X
Physiological Laboratory
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
557885
—
AZ
01
—
L22382013
CORPORATION ID#
AZ
Enumeration date
12/07/2017
Last updated
02/26/2026
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