=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841587656
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DALE RODRIGUE EYECARE CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2011
-----------------------------------------------------
Last Update Date | 07/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 58 STATE ST
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04330-5124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-623-5099
-----------------------------------------------------
Fax | 207-623-7124
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 58 STATE ST
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04330-5124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-623-5099
-----------------------------------------------------
Fax | 207-623-7124
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DALE L RODRIGUE
-----------------------------------------------------
Credential | O.D
-----------------------------------------------------
Telephone | 207-623-5099
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT690
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------