Provider Demographics
NPI:1861677007
Name:BEKS SPEKS EYEWEAR BOUTIQUE
Entity Type:Organization
Organization Name:BEKS SPEKS EYEWEAR BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:BRADTKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-875-2344
Mailing Address - Street 1:1314 9TH ST SE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:DYERSVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52040-2333
Mailing Address - Country:US
Mailing Address - Phone:563-875-2344
Mailing Address - Fax:563-875-2344
Practice Address - Street 1:1314 9TH ST SE
Practice Address - Street 2:SUITE 2
Practice Address - City:DYERSVILLE
Practice Address - State:IA
Practice Address - Zip Code:52040-2333
Practice Address - Country:US
Practice Address - Phone:563-875-2344
Practice Address - Fax:563-875-2344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0449512Medicaid