1104461805 NPI number — THIRD STREET COMMUNITY CLINIC, INC.

Table of content: (NPI 1104461805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104461805 NPI number — THIRD STREET COMMUNITY CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THIRD STREET COMMUNITY CLINIC, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104461805
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1404 PARK AVE W
Provider Second Line Business Mailing Address:
STE 2
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44906-2633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-522-6191
Provider Business Mailing Address Fax Number:
419-525-6723

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
309 ARTHUR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44805-3206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
567-217-7778
Provider Business Practice Location Address Fax Number:
419-525-6723
Provider Enumeration Date:
11/18/2019

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
PEGGY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
419-522-6191

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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