Provider Demographics
NPI:1346624061
Name:GLASSHOUSE OPTICAL, INC
Entity Type:Organization
Organization Name:GLASSHOUSE OPTICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOUZON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-625-0809
Mailing Address - Street 1:30 N EMERSON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-8895
Mailing Address - Country:US
Mailing Address - Phone:317-881-3937
Mailing Address - Fax:
Practice Address - Street 1:1100 SOUTHFIELD DR
Practice Address - Street 2:SUITE 1320
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-4498
Practice Address - Country:US
Practice Address - Phone:317-839-7300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-13
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN156FX1800X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN7427220001Medicare NSC