Healthcare Provider Details

I. General information

NPI: 1346624061
Provider Name (Legal Business Name): GLASSHOUSE OPTICAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2015
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SOUTHFIELD DR SUITE 1320
PLAINFIELD IN
46168-4498
US

IV. Provider business mailing address

30 N EMERSON AVE
GREENWOOD IN
46143-8895
US

V. Phone/Fax

Practice location:
  • Phone: 317-839-7300
  • Fax:
Mailing address:
  • Phone: 317-881-3937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: AMANDA LOUZON
Title or Position: OPTICAL MANAGER
Credential:
Phone: 908-625-0809