Provider Demographics
NPI:1265820815
Name:SPEC SHOPPE II
Entity type:Organization
Organization Name:SPEC SHOPPE II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:FARNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-783-2870
Mailing Address - Street 1:301 N PARK ST
Mailing Address - Street 2:
Mailing Address - City:STANBERRY
Mailing Address - State:MO
Mailing Address - Zip Code:64489-1245
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 N PARK ST
Practice Address - Street 2:
Practice Address - City:STANBERRY
Practice Address - State:MO
Practice Address - Zip Code:64489-1245
Practice Address - Country:US
Practice Address - Phone:660-783-2870
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO22104119156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty