Healthcare Provider Details

I. General information

NPI: 1609841360
Provider Name (Legal Business Name): SAMMY L PELLETIER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 10/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

764 ROUTE ONE UNIT 6
YORK ME
03909-5879
US

IV. Provider business mailing address

764 ROUTE ONE UNIT 6
YORK ME
03909-5879
US

V. Phone/Fax

Practice location:
  • Phone: 207-363-7555
  • Fax: 207-363-1711
Mailing address:
  • Phone: 207-363-7555
  • Fax: 207-363-1711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT729
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: