Provider Demographics
NPI:1578817763
Name:MANCHESTER MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MANCHESTER MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BH ADMINISTRATION SECRETARY
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAKOBOSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-533-3494
Mailing Address - Street 1:71 HAYNES ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4131
Mailing Address - Country:US
Mailing Address - Phone:860-646-1222
Mailing Address - Fax:860-647-6831
Practice Address - Street 1:71 HAYNES ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4131
Practice Address - Country:US
Practice Address - Phone:860-646-1222
Practice Address - Fax:860-647-6831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-09
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0025251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty