Provider Demographics
NPI:1780910687
Name:POULIN OPTICIAN INC
Entity type:Organization
Organization Name:POULIN OPTICIAN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:MICHAUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-872-6311
Mailing Address - Street 1:117 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-6621
Mailing Address - Country:US
Mailing Address - Phone:207-872-6311
Mailing Address - Fax:207-872-6311
Practice Address - Street 1:117 MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-6621
Practice Address - Country:US
Practice Address - Phone:207-872-6311
Practice Address - Fax:207-872-6311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME112880000Medicaid