Provider Demographics
NPI:1386839025
Name:SPEC SHOPPE
Entity Type:Organization
Organization Name:SPEC SHOPPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ISRAELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-486-3937
Mailing Address - Street 1:7121 A ST
Mailing Address - Street 2:SUITE #202
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-4289
Mailing Address - Country:US
Mailing Address - Phone:402-486-3937
Mailing Address - Fax:
Practice Address - Street 1:7121 A ST
Practice Address - Street 2:SUITE #202
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-4289
Practice Address - Country:US
Practice Address - Phone:402-486-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
NE1303970001Medicare NSC