Healthcare Provider Details

I. General information

NPI: 1205038544
Provider Name (Legal Business Name): OPTOMETRIC ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 01/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

168 EAST AVE
LEWISTON ME
04240-5626
US

IV. Provider business mailing address

168 EAST AVE
LEWISTON ME
04240-5626
US

V. Phone/Fax

Practice location:
  • Phone: 207-784-3564
  • Fax: 207-782-2541
Mailing address:
  • Phone: 207-784-3564
  • Fax: 207-782-2541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number
License Number StateME

VIII. Authorized Official

Name: MRS. LINDA S. BOUDREAU
Title or Position: OFFICE MANAGER
Credential:
Phone: 207-784-3564