Provider Demographics
NPI:1265506596
Name:MANCHESTER CLINIC, LLC
Entity type:Organization
Organization Name:MANCHESTER CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-982-2102
Mailing Address - Street 1:PO BOX 30
Mailing Address - Street 2:
Mailing Address - City:NORTH MANCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46962-0030
Mailing Address - Country:US
Mailing Address - Phone:260-982-2102
Mailing Address - Fax:
Practice Address - Street 1:1104 N WAYNE ST
Practice Address - Street 2:
Practice Address - City:NORTH MANCHESTER
Practice Address - State:IN
Practice Address - Zip Code:46962-1001
Practice Address - Country:US
Practice Address - Phone:260-982-2102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN221600Medicare ID - Type Unspecified