Basic Information
| Provider Information | |||||||||
| NPI: | 1104461805 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THIRD STREET COMMUNITY CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449062633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195226191 | ||||||||
| FaxNumber: | 4195256723 | ||||||||
| Practice Location | |||||||||
| Address1: | 309 ARTHUR ST | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448053206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5672177778 | ||||||||
| FaxNumber: | 4195256723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2019 | ||||||||
| LastUpdateDate: | 02/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | JEREMY | ||||||||
| AuthorizedOfficialFirstName: | THERESA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 4195226191 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.