Provider Demographics
NPI:1215942792
Name:SPECTACLE SHOP, INC.
Entity type:Organization
Organization Name:SPECTACLE SHOP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:434-973-8636
Mailing Address - Street 1:20251 LONG LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-8607
Mailing Address - Country:US
Mailing Address - Phone:985-520-5005
Mailing Address - Fax:985-520-5060
Practice Address - Street 1:1047 MILLMONT ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-4866
Practice Address - Country:US
Practice Address - Phone:434-979-7730
Practice Address - Fax:434-977-7512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101000736332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009280006Medicaid
VA009280006Medicaid