Provider Demographics
NPI:1154511202
Name:THIRD STREET HOME
Entity Type:Organization
Organization Name:THIRD STREET HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMALIA
Authorized Official - Middle Name:SIMONA
Authorized Official - Last Name:BONDAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-610-6974
Mailing Address - Street 1:1053 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-8001
Mailing Address - Country:US
Mailing Address - Phone:480-610-6974
Mailing Address - Fax:480-610-6974
Practice Address - Street 1:1053 E 3RD ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-8001
Practice Address - Country:US
Practice Address - Phone:480-610-6974
Practice Address - Fax:480-610-6974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH-4846310400000X, 311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
854051Medicare PIN