Provider Demographics
NPI:1952671356
Name:MANCHESTER INTERVENTIONAL SPINE, LLC
Entity Type:Organization
Organization Name:MANCHESTER INTERVENTIONAL SPINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:JORGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-622-4500
Mailing Address - Street 1:27 BOWDOIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:ME
Mailing Address - Zip Code:04351-3554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27 BOWDOIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:ME
Practice Address - Zip Code:04351-3554
Practice Address - Country:US
Practice Address - Phone:207-213-4340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-03
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty