Provider Demographics
NPI:1568118545
Name:SPECTACLE SHOPPE INC.
Entity Type:Organization
Organization Name:SPECTACLE SHOPPE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:PROKOSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-465-4306
Mailing Address - Street 1:2050 SILVER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-5301
Mailing Address - Country:US
Mailing Address - Phone:651-636-3434
Mailing Address - Fax:651-636-4999
Practice Address - Street 1:7204 MINNETONKA BLVD.
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-3210
Practice Address - Country:US
Practice Address - Phone:952-928-7005
Practice Address - Fax:952-234-9970
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECTACLE SHOPPE INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty