MEDICARE: THE 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	152W00000X	Optometrist	0136	MN

General Provider Information

NPI Number	:	1912224767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE SPECTACLE SHOPPE INC

Provider Business Mailing 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

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	:	OWNER
Name	:	MR. DAVID ULRICH
Credential	:
Telephone Number	:	651-636-3434

Provider Enumeration Date	:	05/03/2010
Last Update Date	:	04/11/2016

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