Provider Demographics
NPI:1730884321
Name:SPECTACLE SHOP LLC
Entity type:Organization
Organization Name:SPECTACLE SHOP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HAILEY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SCHELLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-665-9638
Mailing Address - Street 1:415 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-4201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:817 MAIN ST
Practice Address - Street 2:
Practice Address - City:CREIGHTON
Practice Address - State:NE
Practice Address - Zip Code:68729-4003
Practice Address - Country:US
Practice Address - Phone:402-358-3700
Practice Address - Fax:402-358-3700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-03
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier