Provider Demographics
NPI:1841984036
Name:TRI-STATE HEALING INITIATIVE LLC
Entity type:Organization
Organization Name:TRI-STATE HEALING INITIATIVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:RATLIFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-261-7105
Mailing Address - Street 1:17 LACKAWANNA PL APT 318
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2954
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1619 DIEDERICH BLVD STE D1
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KY
Practice Address - Zip Code:41169-1778
Practice Address - Country:US
Practice Address - Phone:952-261-7105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-08
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty