Healthcare Provider Details

I. General information

NPI: 1881984938
Provider Name (Legal Business Name): LAKES REGION OPTICIANS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2011
Last Update Date: 04/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 BAR HARBOR RD
TRENTON ME
04605-5807
US

IV. Provider business mailing address

390 BAR HARBOR RD
TRENTON ME
04605-5807
US

V. Phone/Fax

Practice location:
  • Phone: 207-664-2782
  • Fax: 207-664-2782
Mailing address:
  • Phone: 207-664-2782
  • Fax: 207-664-2782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number1635
License Number StateNH

VIII. Authorized Official

Name: MR. RICH M IRVING
Title or Position: PRESIDENT/DISPENSING OPTICIAN
Credential: REG. OPTICIAN
Phone: 603-524-2050