Provider Demographics
NPI:1144796491
Name:HEALTHY MALE INSTITUTE
Entity Type:Organization
Organization Name:HEALTHY MALE INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:PHERNEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MANIGAT
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:617-694-7172
Mailing Address - Street 1:218 SAWTELL AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-1654
Mailing Address - Country:US
Mailing Address - Phone:617-694-7172
Mailing Address - Fax:
Practice Address - Street 1:425 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-2533
Practice Address - Country:US
Practice Address - Phone:617-694-7172
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)