Provider Demographics
NPI:1821521154
Name:MANCHIN CLINIC OF BRIDGEPORT
Entity Type:Organization
Organization Name:MANCHIN CLINIC OF BRIDGEPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCHIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-848-8800
Mailing Address - Street 1:409 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1752
Mailing Address - Country:US
Mailing Address - Phone:304-848-8800
Mailing Address - Fax:
Practice Address - Street 1:409 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1752
Practice Address - Country:US
Practice Address - Phone:304-848-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN83843-NP-C261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care