Healthcare Provider Details

I. General information

NPI: 1063401693
Provider Name (Legal Business Name): CASCO BAY EYECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 THADEUS ST
SOUTH PORTLAND ME
04106-6259
US

IV. Provider business mailing address

PO BOX 7487
PORTLAND ME
04112-7487
US

V. Phone/Fax

Practice location:
  • Phone: 207-885-8686
  • Fax: 207-883-7154
Mailing address:
  • Phone: 207-885-8686
  • Fax: 207-883-7154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MS. REBECCA DARLING
Title or Position: GROUP ADMINISTRATOR
Credential:
Phone: 207-885-8686