Healthcare Provider Details

I. General information

NPI: 1790101871
Provider Name (Legal Business Name): MR. MARK ANDREW ROUILLARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2014
Last Update Date: 03/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 OAK WOODS RD
NORTH BERWICK ME
03906-6121
US

IV. Provider business mailing address

62 OAK WOODS RD
NORTH BERWICK ME
03906-6121
US

V. Phone/Fax

Practice location:
  • Phone: 207-432-1777
  • Fax:
Mailing address:
  • Phone: 207-432-1777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: