Organization
DISTINCTIVE EYEWEAR, LLC
Active
Other names
Northwest Eyewear
Organization subpart
No
Provider details
NPI number
Authorized official
KELLY PETTENGILL (CREDENTIALING & DATA MANAGEMENT)
(763) 416-7629
Entity
Organization
Contact information
Practice address
2601 39TH AVE NE, ST. ANTHONY, MN 55421
(763) 416-7674
(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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