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General NPI Number Information
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NPI Number | 1447754312
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Entity Type | Organization
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Legal Business Name | PINE TREE EYE ASSOCIATES, PA
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Dates
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Enumeration Date | 03/23/2018
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Last Update Date | 03/23/2018
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Provider Practice Location Address
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Address Line | 166 SILVER ST
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City | WATERVILLE
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State | ME
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Zip | 04901-5815
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Country | US
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Telephone | 207-873-3500
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Fax | 207-873-6167
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Provider Business Mailing Address
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Address Line | 166 SILVER ST
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City | WATERVILLE
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State | ME
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Zip | 04901-5815
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Country | US
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Telephone | 207-873-3500
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Fax | 207-873-6167
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Authorized Official
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Title or Position | OWNER/OPTOMETRIST
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Name | ARIELLE L COSTELLO
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Credential | OD
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Telephone | 207-873-3500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPT942
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License Number State | ME
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