Healthcare Provider Details

I. General information

NPI: 1952591331
Provider Name (Legal Business Name): CHILD HEALTH SERVICS (TEEN HEALTH CLINIC)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2007
Last Update Date: 11/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 ELM STREET
MANCHESTER NH
03101
US

IV. Provider business mailing address

1245 ELM STREET
MANCHESTER NH
03101
US

V. Phone/Fax

Practice location:
  • Phone: 603-629-9707
  • Fax: 603-629-9694
Mailing address:
  • Phone: 603-668-6629
  • Fax: 603-622-7680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LISA A. DIBRIGIDA, MD
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 603-668-6629