NPIMap

Organization Active NPI

Distinctive Eyewear, LLC

  • Eyewear Supplier
  • Maple Grove, MN
National Provider Identifier
1043392632
Registry record updated Mar 18, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Eyewear SupplierTaxonomy code 332H00000X
Legal business name
DISTINCTIVE EYEWEAR, LLC
Practice address
12000 Elm Creek Blvd N Ste 100
Maple Grove, MN 55369-7074
Phone
(763) 416-7653
Fax
(763) 416-7634
NPI assigned
Oct 20, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 18, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kelly Pettengill
Title
Credentialing and Data Management
Phone
(763) 416-7629

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
OpticianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 156FX1800X
Eyewear Supplier 332H00000X Primary

Addresses

Primary practice location

12000 Elm Creek Blvd N Ste 100
Maple Grove, MN 55369-7074

Mailing address

8401 Golden Valley Rd Ste 330
Golden Valley, MN 55427-4488
Phone (763) 416-7629

Other names 1

  • Northwest Eyewear Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100930018469 MN DME Supplier - Optician 4789897398 Practice locations: Maple Grove, MN

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Distinctive Eyewear LLC5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1161302400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1584489600000",
    "number": "1043392632",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8401 GOLDEN VALLEY RD STE 330",
            "city": "GOLDEN VALLEY",
            "state": "MN",
            "postal_code": "554274488",
            "telephone_number": "763-416-7629",
            "fax_number": "763-383-4147"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12000 ELM CREEK BLVD N STE 100",
            "city": "MAPLE GROVE",
            "state": "MN",
            "postal_code": "553697074",
            "telephone_number": "763-416-7653",
            "fax_number": "763-416-7634"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DISTINCTIVE EYEWEAR, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-20",
        "last_updated": "2020-03-18",
        "certification_date": "2020-03-18",
        "status": "A",
        "authorized_official_last_name": "PETTENGILL",
        "authorized_official_first_name": "KELLY",
        "authorized_official_title_or_position": "CREDENTIALING AND DATA MANAGEMENT",
        "authorized_official_telephone_number": "763-416-7629"
    },
    "taxonomies": [
        {
            "code": "156FX1800X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Technician/Technologist, Optician",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "332H00000X",
            "taxonomy_group": "",
            "desc": "Eyewear Supplier",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Northwest Eyewear",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Northwest Eyewear",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Maple Grove, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 18, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.