Provider Demographics
NPI:1619668522
Name:HERCULES, MAXINE MARIE
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:MARIE
Last Name:HERCULES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:288 LARKIN DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-4911
Mailing Address - Country:US
Mailing Address - Phone:845-783-1112
Mailing Address - Fax:845-783-1161
Practice Address - Street 1:288 LARKIN DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-4911
Practice Address - Country:US
Practice Address - Phone:845-783-1112
Practice Address - Fax:845-783-1161
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009072156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician