Provider Demographics
NPI:1992792600
Name:SPECTACLE SHOP LLC
Entity type:Organization
Organization Name:SPECTACLE SHOP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:HAILEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHELLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-665-9638
Mailing Address - Street 1:PO BOX 819
Mailing Address - Street 2:415 W 3RD ST
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-0819
Mailing Address - Country:US
Mailing Address - Phone:605-665-9638
Mailing Address - Fax:605-665-0526
Practice Address - Street 1:415 W 3RD ST
Practice Address - Street 2:
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-4201
Practice Address - Country:US
Practice Address - Phone:605-665-9638
Practice Address - Fax:605-665-0526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100249545-00Medicaid
SD9281510Medicaid