Healthcare Provider Details

I. General information

NPI: 1457690133
Provider Name (Legal Business Name): DISTINCTIVE EYEWEAR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2013
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8501 GOLDEN VALLEY RD STE 100
GOLDEN VALLEY MN
55427-4472
US

IV. Provider business mailing address

8401 GOLDEN VALLEY RD STE 330
GOLDEN VALLEY MN
55427-4488
US

V. Phone/Fax

Practice location:
  • Phone: 763-416-7655
  • Fax: 763-416-7634
Mailing address:
  • Phone: 763-416-7629
  • Fax: 763-383-4147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FC0800X
TaxonomyContact Lens Technician/Technologist
License Number
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: KELLY PETTENGILL
Title or Position: CREDENTIALING AND DATA MANAGEMENT
Credential:
Phone: 763-416-7629