Provider Demographics
NPI:1386173847
Name:SPECTACLE ENVY
Entity type:Organization
Organization Name:SPECTACLE ENVY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:NCLDO
Authorized Official - Phone:336-231-3135
Mailing Address - Street 1:66 COURT SQ
Mailing Address - Street 2:
Mailing Address - City:MOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27028-2415
Mailing Address - Country:US
Mailing Address - Phone:336-231-3135
Mailing Address - Fax:336-753-1335
Practice Address - Street 1:66 COURT SQ
Practice Address - Street 2:
Practice Address - City:MOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27028-2415
Practice Address - Country:US
Practice Address - Phone:336-231-3135
Practice Address - Fax:336-753-1335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2087156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCPE-VGN87USX7Medicaid