Provider Demographics
NPI:1447754312
Name:PINE TREE EYE ASSOCIATES, PA
Entity Type:Organization
Organization Name:PINE TREE EYE ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:ARIELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:207-873-3500
Mailing Address - Street 1:166 SILVER ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-5815
Mailing Address - Country:US
Mailing Address - Phone:207-873-3500
Mailing Address - Fax:207-873-6167
Practice Address - Street 1:166 SILVER ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-5815
Practice Address - Country:US
Practice Address - Phone:207-873-3500
Practice Address - Fax:207-873-6167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT942152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty