Provider Demographics
NPI:1457690133
Name:DISTINCTIVE EYEWEAR, LLC
Entity type:Organization
Organization Name:DISTINCTIVE EYEWEAR, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AND DATA MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTENGILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-416-7629
Mailing Address - Street 1:8401 GOLDEN VALLEY RD STE 330
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-4488
Mailing Address - Country:US
Mailing Address - Phone:763-416-7629
Mailing Address - Fax:763-383-4147
Practice Address - Street 1:8501 GOLDEN VALLEY RD STE 100
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4472
Practice Address - Country:US
Practice Address - Phone:763-416-7655
Practice Address - Fax:763-416-7634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-31
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332H00000X
MN156FC0800X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact LensGroup - Multi-Specialty