Provider Demographics
NPI:1831375427
Name:SPECTRUM HEALTHCARE MANCHESTER, LLC
Entity type:Organization
Organization Name:SPECTRUM HEALTHCARE MANCHESTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CHIEF EXECUTIVE OFFIC
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:DICKSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:860-871-5454
Mailing Address - Street 1:565 VERNON ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-2409
Mailing Address - Country:US
Mailing Address - Phone:860-643-5151
Mailing Address - Fax:
Practice Address - Street 1:565 VERNON ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-2409
Practice Address - Country:US
Practice Address - Phone:860-643-5151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1014-C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000010140Medicaid
CT075013Medicare Oscar/Certification