Provider Demographics
NPI:1760497200
Name:MANNA INC
Entity Type:Organization
Organization Name:MANNA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:RAE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-990-2870
Mailing Address - Street 1:PO BOX 2763
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-2763
Mailing Address - Country:US
Mailing Address - Phone:207-990-2870
Mailing Address - Fax:207-990-2298
Practice Address - Street 1:629 MAIN ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6848
Practice Address - Country:US
Practice Address - Phone:207-990-2870
Practice Address - Fax:207-990-2298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
ME453264324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Not Answered324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility