Provider Demographics
NPI:1760864649
Name:THIRD STREET COMMUNITY CLINIC
Entity Type:Organization
Organization Name:THIRD STREET COMMUNITY CLINIC
Other - Org Name:ASHLAND HEALTH AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-526-7880
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 1:309 ARTHUR ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-3206
Practice Address - Country:US
Practice Address - Phone:567-217-7778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-26
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X, 261QM0850X, 261QM0855X, 261QP1100X, 261QP2300X, 3336C0002X
OHCOA.17471-NP363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No3336C0002XSuppliersPharmacyClinic PharmacyGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty