Provider Demographics
NPI:1376791590
Name:STATE STREET OPTICS
Entity Type:Organization
Organization Name:STATE STREET OPTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISE
Authorized Official - Middle Name:M
Authorized Official - Last Name:AUXIER
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:207-992-2888
Mailing Address - Street 1:207 STATE ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5412
Mailing Address - Country:US
Mailing Address - Phone:207-992-2888
Mailing Address - Fax:
Practice Address - Street 1:207 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5412
Practice Address - Country:US
Practice Address - Phone:207-992-2888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME5188220001Medicare UPIN