Healthcare Provider Details

I. General information

NPI: 1154511202
Provider Name (Legal Business Name): THIRD STREET HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1053 E 3RD ST
MESA AZ
85203-8001
US

IV. Provider business mailing address

1053 E 3RD ST
MESA AZ
85203-8001
US

V. Phone/Fax

Practice location:
  • Phone: 480-610-6974
  • Fax: 480-610-6974
Mailing address:
  • Phone: 480-610-6974
  • Fax: 480-610-6974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberALH-4846
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberALH-4846
License Number StateAZ

VIII. Authorized Official

Name: AMALIA SIMONA BONDAR
Title or Position: MANAGER
Credential:
Phone: 480-610-6974