Healthcare Provider Details

I. General information

NPI: 1245900620
Provider Name (Legal Business Name): MANCHESTER BEDFORD MYOSKELETAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 RIVERWAY PL
BEDFORD NH
03110-6730
US

IV. Provider business mailing address

111 RIVERWAY PL
BEDFORD NH
03110-6730
US

V. Phone/Fax

Practice location:
  • Phone: 603-622-1112
  • Fax: 888-965-6870
Mailing address:
  • Phone: 603-622-1112
  • Fax: 888-965-6870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JOEL KOUYOUMJIAN
Title or Position: MANAGER
Credential: LMT MMT
Phone: 603-622-1112