Provider Demographics
NPI:1396867883
Name:LOOKING GLASS
Entity Type:Organization
Organization Name:LOOKING GLASS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:ELLYN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-577-6506
Mailing Address - Street 1:31 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-1720
Mailing Address - Country:US
Mailing Address - Phone:843-723-4854
Mailing Address - Fax:843-723-9835
Practice Address - Street 1:31 SMITH ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-1720
Practice Address - Country:US
Practice Address - Phone:843-723-4854
Practice Address - Fax:843-723-9835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0238130001Medicare NSC