Healthcare Provider Details

I. General information

NPI: 1225018740
Provider Name (Legal Business Name): WATERBORO VILLAGE PEDIATRICS LLC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 SOKOKIS TRAIL
EAST WATERBORO ME
04030
US

IV. Provider business mailing address

PO BOX 1849
LEWISTON ME
04241-1849
US

V. Phone/Fax

Practice location:
  • Phone: 207-247-6742
  • Fax: 207-247-6114
Mailing address:
  • Phone: 207-784-2554
  • Fax: 207-777-5363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: KEASHA DANIELLE MARESCOT
Title or Position: CO OWNER PARTNER
Credential: MD
Phone: 207-247-6742