Healthcare Provider Details

I. General information

NPI: 1922088335
Provider Name (Legal Business Name): TIMOTHY DAVID RIOUX OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 MEADOW LN
FORT KENT ME
04743-1203
US

IV. Provider business mailing address

29 MEADOW LN
FORT KENT ME
04743-1203
US

V. Phone/Fax

Practice location:
  • Phone: 207-834-3333
  • Fax: 207-834-6095
Mailing address:
  • Phone: 207-834-3333
  • Fax: 207-834-6095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT773TA
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: