Healthcare Provider Details

I. General information

NPI: 1992700132
Provider Name (Legal Business Name): WOLF EYE ASSOCIATES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 12/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 MAIN ST
LEWISTON ME
04240-7053
US

IV. Provider business mailing address

249 MAIN ST
LEWISTON ME
04240-7053
US

V. Phone/Fax

Practice location:
  • Phone: 207-783-9653
  • Fax: 207-786-4362
Mailing address:
  • Phone: 207-783-9653
  • Fax: 207-786-4362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number36163
License Number StateME

VIII. Authorized Official

Name: RUTH ANNE BROCHU
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 207-783-9653