Healthcare Provider Details

I. General information

NPI: 1760497200
Provider Name (Legal Business Name): MANNA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629 MAIN ST
BANGOR ME
04401-6848
US

IV. Provider business mailing address

PO BOX 2763
BANGOR ME
04402-2763
US

V. Phone/Fax

Practice location:
  • Phone: 207-990-2870
  • Fax: 207-990-2298
Mailing address:
  • Phone: 207-990-2870
  • Fax: 207-990-2298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number453264
License Number StateME

VIII. Authorized Official

Name: MARK RAE
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 207-990-2870