=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295918233
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YORK FAMILY EYECARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2007
-----------------------------------------------------
Last Update Date | 09/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 764 US ROUTE 1
-----------------------------------------------------
City | YORK
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 03909-5883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-363-7555
-----------------------------------------------------
Fax | 207-363-1711
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 764 US ROUTE 1
-----------------------------------------------------
City | YORK
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 03909-5883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-363-7555
-----------------------------------------------------
Fax | 207-363-1711
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SAMMY LEE PELLETIER
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 207-363-7555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT729
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------