Healthcare Provider Details

I. General information

NPI: 1467010504
Provider Name (Legal Business Name): ABIGAIL ROSE CARR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ABIGAIL ROSE HEROTH

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
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 TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14478468
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT1015
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: