Provider Demographics
NPI:1447343926
Name:KITTERY OPTOMETRIC ASSOCIATES, PLLC
Entity type:Organization
Organization Name:KITTERY OPTOMETRIC ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:207-439-0410
Mailing Address - Street 1:99 US ROUTE 1 BYP
Mailing Address - Street 2:SUITE A
Mailing Address - City:KITTERY
Mailing Address - State:ME
Mailing Address - Zip Code:03904-1570
Mailing Address - Country:US
Mailing Address - Phone:207-439-0410
Mailing Address - Fax:207-439-8353
Practice Address - Street 1:99 US ROUTE 1 BYP
Practice Address - Street 2:SUITE A
Practice Address - City:KITTERY
Practice Address - State:ME
Practice Address - Zip Code:03904-1570
Practice Address - Country:US
Practice Address - Phone:207-439-0410
Practice Address - Fax:207-439-8353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME117490000Medicaid
ME117490000Medicaid
MEMM0691Medicare ID - Type Unspecified