Healthcare Provider Details

I. General information

NPI: 1679552251
Provider Name (Legal Business Name): ROBERT LORENZO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 11/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 CHASE AVE
WATERVILLE ME
04901-4624
US

IV. Provider business mailing address

30 CHASE AVE
WATERVILLE ME
04901-4624
US

V. Phone/Fax

Practice location:
  • Phone: 207-872-4400
  • Fax: 207-861-5299
Mailing address:
  • Phone: 207-872-4400
  • Fax: 207-861-5299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number016370
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: