Provider Demographics
NPI:1205038544
Name:OPTOMETRIC ASSOCIATES PA
Entity Type:Organization
Organization Name:OPTOMETRIC ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:BOUDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-784-3564
Mailing Address - Street 1:168 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5626
Mailing Address - Country:US
Mailing Address - Phone:207-784-3564
Mailing Address - Fax:207-782-2541
Practice Address - Street 1:168 EAST AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5626
Practice Address - Country:US
Practice Address - Phone:207-784-3564
Practice Address - Fax:207-782-2541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME152W00000X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME0324520001Medicare NSC