Provider Demographics
NPI:1851569776
Name:SPECTACLE SHOPPE LLC
Entity Type:Organization
Organization Name:SPECTACLE SHOPPE LLC
Other - Org Name:THE SPECTACLE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:RYDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-561-7170
Mailing Address - Street 1:224 TOM MILLER RD
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-6427
Mailing Address - Country:US
Mailing Address - Phone:518-561-6129
Mailing Address - Fax:
Practice Address - Street 1:224 TOM MILLER RD
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-6427
Practice Address - Country:US
Practice Address - Phone:518-561-6129
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01649265Medicaid
NY01440642Medicaid
NY01649265Medicaid