MEDICARE: SPECTACLE SHOPPE INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier
2	152W00000X	Optometrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6C261SP	OTHER	MN	BCBS
2	93268	OTHER	MN	PREFERRED ONE

General Provider Information

NPI Number	:	1376680165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPECTACLE SHOPPE INC.

Provider Business Mailing Address
First Line	:	2050 SILVER LAKE RD NW
Second Line	:
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-5301
Country	:	US
Telephone Number	:	651-797-4834
Fax Number	:	651-788-9153

Provider Business Practice Location Address
First Line	:	1089 GRAND AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-3002
Country	:	US
Telephone Number	:	651-797-4834
Fax Number	:	651-788-9153

Authorized Official
Title or Position	:	AUTHORIZED OFFICAL/COO
Name	:	BETH SEATON ULRICH
Credential	:
Telephone Number	:	651-636-3434

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	03/21/2025

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