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NPI Code Detail

MEDICARE: DISTINCTIVE EYEWEAR LLC

MEDICARE: DISTINCTIVE EYEWEAR LLC
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
1156FX1800XOptician
2332H00000XEyewear Supplier

General Provider Information

NPI Number : 1609958230
Entity Type Code : Organization
Provider Name (Legal Business Name) : DISTINCTIVE EYEWEAR LLC
Provider Business Mailing Address
First Line : 8401 GOLDEN VALLEY RD STE 330
Second Line :
City : GOLDEN VALLEY
State : MN
Zip : 55427-4488
Country : US
Telephone Number : 763-416-7629
Fax Number : 763-383-4147
Provider Business Practice Location Address
First Line : 250 CENTRAL AVE N STE 106
Second Line :
City : WAYZATA
State : MN
Zip : 55391-1207
Country : US
Telephone Number : 763-416-7654
Fax Number : 763-416-7634
Authorized Official
Title or Position : CREDENTIALING AND DATA MANAGEMENT
Name : KELLY PETTENGILL
Credential :
Telephone Number : 763-416-7629
Provider Enumeration Date : 10/20/2006
Last Update Date : 03/18/2020

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1326425364 — DR. CHRISTOPHER KRUTHOFF OD
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Directions to “DISTINCTIVE EYEWEAR LLC ” Practice Location

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