Healthcare Provider Details

I. General information

NPI: 1952671356
Provider Name (Legal Business Name): MANCHESTER INTERVENTIONAL SPINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2012
Last Update Date: 05/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 BOWDOIN ST
MANCHESTER ME
04351-3554
US

IV. Provider business mailing address

27 BOWDOIN ST
MANCHESTER ME
04351-3554
US

V. Phone/Fax

Practice location:
  • Phone: 207-213-4340
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS J JORGENSEN
Title or Position: MEDICAL DIRECTOR
Credential: D.O.
Phone: 207-622-4500