Provider Demographics
NPI:1750500013
Name:PINE STATE LOW VISION SERVICES LLC
Entity Type:Organization
Organization Name:PINE STATE LOW VISION SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MACKINNON
Authorized Official - Suffix:
Authorized Official - Credentials:OTR L
Authorized Official - Phone:207-329-2497
Mailing Address - Street 1:19 OLD COLONY LN
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND CENTER
Mailing Address - State:ME
Mailing Address - Zip Code:04021-3053
Mailing Address - Country:US
Mailing Address - Phone:207-329-2497
Mailing Address - Fax:207-286-3218
Practice Address - Street 1:19 OLD COLONY LN
Practice Address - Street 2:
Practice Address - City:CUMBERLAND CENTER
Practice Address - State:ME
Practice Address - Zip Code:04021-3053
Practice Address - Country:US
Practice Address - Phone:207-329-2497
Practice Address - Fax:207-286-3218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME0000825Medicare PIN