Provider Demographics
NPI:1649151580
Name:REDWINE, PRESTON (LMT)
Entity type:Individual
Prefix:
First Name:PRESTON
Middle Name:
Last Name:REDWINE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 ALFRED ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-3267
Mailing Address - Country:US
Mailing Address - Phone:207-494-4695
Mailing Address - Fax:
Practice Address - Street 1:17 LINCOLN ST STE 16
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-4633
Practice Address - Country:US
Practice Address - Phone:207-494-4695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-09
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT7190225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty