=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861514093
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPECTACLES DISTINCTIVE EYEWEAR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3601 S CLARKSON ST SUITE 115
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80113-3944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-781-9151
-----------------------------------------------------
Fax | 303-781-1343
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3601 S CLARKSON ST SUITE 115
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80113-3944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-781-9151
-----------------------------------------------------
Fax | 303-781-1343
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTICIAN
-----------------------------------------------------
Name | MRS. RITA SANDOVAL
-----------------------------------------------------
Credential | OPTICIAN
-----------------------------------------------------
Telephone | 303-781-9151
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------