Provider Demographics
NPI:1710517339
Name:THIRD STREET COMMUNITY CLINIC, INC.
Entity Type:Organization
Organization Name:THIRD STREET COMMUNITY CLINIC, INC.
Other - Org Name:9TH STREET DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:JEREMY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-522-6191
Mailing Address - Street 1:600 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-2633
Mailing Address - Country:US
Mailing Address - Phone:419-522-6191
Mailing Address - Fax:419-525-6723
Practice Address - Street 1:431 E 9TH ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-1903
Practice Address - Country:US
Practice Address - Phone:419-289-1430
Practice Address - Fax:419-525-6723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-23
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty