1649599119 NPI number — THIRD STREET COMMUNITY CLINIC, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649599119 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:
1649599119
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:
419-522-0493

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
770 BALGREEN DRIVE
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
MANSFIELD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44906-2633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-522-6800
Provider Business Practice Location Address Fax Number:
419-522-6816
Provider Enumeration Date:
05/24/2010

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:
419-526-7880

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)

  • Identifier: 3111957 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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