Healthcare Provider Details

I. General information

NPI: 1376680165
Provider Name (Legal Business Name): SPECTACLE SHOPPE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1089 GRAND AVE
SAINT PAUL MN
55105-3002
US

IV. Provider business mailing address

2050 SILVER LAKE RD NW
NEW BRIGHTON MN
55112-5301
US

V. Phone/Fax

Practice location:
  • Phone: 651-797-4834
  • Fax: 651-788-9153
Mailing address:
  • Phone: 651-797-4834
  • Fax: 651-788-9153

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