Provider Demographics
NPI:1235457722
Name:THE SPECTACLE SHOPPE INC
Entity Type:Organization
Organization Name:THE SPECTACLE SHOPPE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ULRICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-636-3434
Mailing Address - Street 1:1178 BURNSVILLE CTR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-6218
Mailing Address - Country:US
Mailing Address - Phone:952-892-6666
Mailing Address - Fax:952-892-6876
Practice Address - Street 1:1178 BURNSVILLE CTR
Practice Address - Street 2:SUITE 201
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-6218
Practice Address - Country:US
Practice Address - Phone:952-892-6666
Practice Address - Fax:952-892-6876
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE SPECTACLE SHOPPE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-10
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0136152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty