Healthcare Provider Details

I. General information

NPI: 1043412869
Provider Name (Legal Business Name): THIRD STREET ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 12/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 N 3RD ST
EASTON PA
18042-3642
US

IV. Provider business mailing address

41 N 3RD ST
EASTON PA
18042-3642
US

V. Phone/Fax

Practice location:
  • Phone: 610-258-6271
  • Fax: 610-258-2112
Mailing address:
  • Phone: 610-258-6271
  • Fax: 610-258-2112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: MAHPAREH FAKHRAIE
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 610-258-6271