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Organization
DISTINCTIVE EYEWEAR LLC
Active
Organization
DISTINCTIVE EYEWEAR LLC
Active
Other names
Northwest Eyewear
Organization subpart
No
Provider details
NPI number
Authorized official
KELLY PETTENGILL (CREDENTIALING AND DATA MANAGEMENT)
(763) 416-7629
Entity
Organization
Contact information
Practice address
250 CENTRAL AVE N STE 106, WAYZATA, MN 55391-1207
(763) 416-7654
(763) 416-7634
Mailing address
8401 GOLDEN VALLEY RD STE 330, GOLDEN VALLEY, MN 55427-4488
(763) 416-7629
(763) 383-4147
Taxonomy
Speciality
Code
Description
License number
State
156FX1800X
Optician
—
—
332H00000X
Eyewear Supplier
Primary
—
—
Other
Enumeration date
10/20/2006
Last updated
03/18/2020
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