Provider Demographics
NPI:1477624971
Name:EYE FASHIONS OPTICAL SHOPPE INC
Entity Type:Organization
Organization Name:EYE FASHIONS OPTICAL SHOPPE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SCHLAUDERAFF
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-326-0358
Mailing Address - Street 1:202 NW 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744
Mailing Address - Country:US
Mailing Address - Phone:218-326-0358
Mailing Address - Fax:218-326-0566
Practice Address - Street 1:202 NW 1ST AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744
Practice Address - Country:US
Practice Address - Phone:218-326-0358
Practice Address - Fax:218-326-0358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2415152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
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MN593932000Medicaid
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2200897OtherMEDICA GR EX
3C838SCOtherBLUE PLUS
3C838SCOtherBLUE SHIELD
974251008835OtherPREFERRED ONE
3C837EYOtherBLUE SHIELD
3C837EYOtherBLUE PLUS
974251008835OtherCBSA PPO
HP29720OtherHEALTHPARTNERS
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0842720001Medicare NSC