Basic Information
| Provider Information | |||||||||
| NPI: | 1679044739 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED CLINICAL EYECARE OF SOUTHERN MAINE, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 335 MAINE MALL RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041063214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077717968 | ||||||||
| FaxNumber: | 2077717983 | ||||||||
| Practice Location | |||||||||
| Address1: | 335 MAINE MALL RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041063214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077717968 | ||||||||
| FaxNumber: | 2077717983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2018 | ||||||||
| LastUpdateDate: | 02/13/2019 | ||||||||
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| AuthorizedOfficialLastName: | OLMES | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2077717968 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.