Provider Demographics
NPI:1184729915
Name:EYECARE MEDICAL GROUP OPTICAL SHOP
Entity type:Organization
Organization Name:EYECARE MEDICAL GROUP OPTICAL SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFIER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORTY
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CMPE
Authorized Official - Phone:207-791-8234
Mailing Address - Street 1:53 SEWALL STREET
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102
Mailing Address - Country:US
Mailing Address - Phone:207-773-9597
Mailing Address - Fax:207-773-7034
Practice Address - Street 1:53 SEWALL STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102
Practice Address - Country:US
Practice Address - Phone:207-828-2020
Practice Address - Fax:207-773-7034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME109280300Medicaid
ME109280300Medicaid