Provider Demographics
NPI:1083134431
Name:KIDS SPECTACLE SHOP
Entity type:Organization
Organization Name:KIDS SPECTACLE SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DYLON
Authorized Official - Middle Name:
Authorized Official - Last Name:STOREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-807-2720
Mailing Address - Street 1:3248 W 11TH AVENUE PL
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-1061
Mailing Address - Country:US
Mailing Address - Phone:316-807-2720
Mailing Address - Fax:
Practice Address - Street 1:2575 PEARL ST STE 1C
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-3851
Practice Address - Country:US
Practice Address - Phone:303-442-6260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ZIPJOBZ
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-26
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty