=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508841503
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANCHESTER ALLERGY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 765 S MAIN ST SUITE 203
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03102-5141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-668-6444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 765 S MAIN ST SUITE 203
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03102-5141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-668-6444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOHN NADER KALLIEL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 603-668-6444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 7573
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------