Healthcare Provider Details

I. General information

NPI: 1992924518
Provider Name (Legal Business Name): AUDIOLOGY CENTER OF MAINE, LLC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 11/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 BEECHLAND ROAD
ELLSWORTH ME
04605-2639
US

IV. Provider business mailing address

77 BEECHLAND ROAD
ELLSWORTH ME
04605-2639
US

V. Phone/Fax

Practice location:
  • Phone: 207-664-2123
  • Fax: 207-667-0706
Mailing address:
  • Phone: 207-664-2123
  • Fax: 207-667-0706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberAP1053E
License Number StateME

VIII. Authorized Official

Name: MS. MARYELLEN B. TOOTHAKER
Title or Position: OWNER
Credential: MA,CCC-A
Phone: 207-664-2123