Provider Demographics
NPI:1659462067
Name:KENNEBEC EYECARE PA
Entity Type:Organization
Organization Name:KENNEBEC EYECARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:PARADIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:207-872-2797
Mailing Address - Street 1:PO BOX 1438
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04903
Mailing Address - Country:US
Mailing Address - Phone:207-872-2797
Mailing Address - Fax:207-872-2793
Practice Address - Street 1:216 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901
Practice Address - Country:US
Practice Address - Phone:207-872-2797
Practice Address - Fax:207-872-2793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME127280001Medicaid
MEME1705Medicare PIN