Healthcare Provider Details

I. General information

NPI: 1659462067
Provider Name (Legal Business Name): KENNEBEC EYECARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 MAIN ST
WATERVILLE ME
04901-6116
US

IV. Provider business mailing address

216 MAIN ST
WATERVILLE ME
04901-6116
US

V. Phone/Fax

Practice location:
  • Phone: 207-872-2797
  • Fax: 207-872-2793
Mailing address:
  • Phone: 207-872-2797
  • Fax: 207-872-2793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: PETER PARADIS
Title or Position: OWNER
Credential: OD
Phone: 207-872-2797