Healthcare Provider Details

I. General information

NPI: 1184729915
Provider Name (Legal Business Name): EYECARE MEDICAL GROUP OPTICAL SHOP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 SEWALL STREET
PORTLAND ME
04102
US

IV. Provider business mailing address

53 SEWALL STREET
PORTLAND ME
04102
US

V. Phone/Fax

Practice location:
  • Phone: 207-828-2020
  • Fax: 207-773-7034
Mailing address:
  • Phone: 207-773-9597
  • Fax: 207-773-7034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: LYNN SHORTY
Title or Position: CHIEF OPERATING OFFIER
Credential: RN, CMPE
Phone: 207-791-8234