Organization Name: | GRAND SPECTACLE INC |
NPI Number: | 1003935867 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | MATTHEW MCDONOUGH (CERTIFIED OPTICIAN) |
Mailing Address: | 764 Grand Ave Saint Paul |
State: | MN US |
Postal Code: | 551053306 |
Phone Number: | 6512278198 |
Fax Number: | 6512278198 |
NPI Enumeration Date: | 03/29/2007 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 156FX1800X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Eye and Vision Services Providers |
Taxonomy Classification: | Technician/Technologist |
Taxonomy Specialization: | Optician |
Taxonomy Definition: |