Provider Demographics
NPI:1962653923
Name:SPECTACLE SHOPPE LLC
Entity Type:Organization
Organization Name:SPECTACLE SHOPPE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:RASHID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-768-7371
Mailing Address - Street 1:4513 MACCORKLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1408
Mailing Address - Country:US
Mailing Address - Phone:304-768-7371
Mailing Address - Fax:304-720-3628
Practice Address - Street 1:4513 MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1408
Practice Address - Country:US
Practice Address - Phone:304-768-7371
Practice Address - Fax:304-720-3628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-08
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV82110156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6456750001Medicare NSC