Provider Demographics
NPI:1346321973
Name:THE SPECTACLE SHOPPE, INC.
Entity Type:Organization
Organization Name:THE SPECTACLE SHOPPE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROXANA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-686-6111
Mailing Address - Street 1:306 N ROCK RD
Mailing Address - Street 2:STE 10
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2256
Mailing Address - Country:US
Mailing Address - Phone:316-686-6111
Mailing Address - Fax:316-686-7665
Practice Address - Street 1:306 N ROCK RD
Practice Address - Street 2:STE 10
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2256
Practice Address - Country:US
Practice Address - Phone:316-686-6111
Practice Address - Fax:316-686-7665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0304110001Medicare ID - Type Unspecified