Healthcare Provider Details

I. General information

NPI: 1568118545
Provider Name (Legal Business Name): SPECTACLE SHOPPE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2022
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7204 MINNETONKA BLVD.
ST LOUIS PARK MN
55426-3210
US

IV. Provider business mailing address

2050 SILVER LAKE RD
NEW BRIGHTON MN
55112-5301
US

V. Phone/Fax

Practice location:
  • Phone: 952-928-7005
  • Fax: 952-234-9970
Mailing address:
  • Phone: 651-636-3434
  • Fax: 651-636-4999

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: MRS. BETH ULRICH
Title or Position: OWNER
Credential:
Phone: 952-928-7005