Healthcare Provider Details

I. General information

NPI: 1386965770
Provider Name (Legal Business Name): SPECTACLE SHOPPE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2010
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 HENNEPIN AVE
MINNEAPOLIS MN
55405-2606
US

IV. Provider business mailing address

2405 HENNEPIN AVE
MINNEAPOLIS MN
55405-2606
US

V. Phone/Fax

Practice location:
  • Phone: 612-584-4142
  • Fax: 612-584-4147
Mailing address:
  • Phone: 612-584-4142
  • Fax: 612-584-4147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: BETH SEATON ULRICH
Title or Position: AUTHORIZED OFFICAL/COO
Credential:
Phone: 651-636-3434