MEDICARE: LOOKING GLASS EYECARE PROFESSIONALS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	5806	OH

General Provider Information

NPI Number	:	1881839983
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOOKING GLASS EYECARE PROFESSIONALS LLC

Provider Business Mailing Address
First Line	:	631 N UNION ST
Second Line	:
City	:	LOUDONVILLE
State	:	OH
Zip	:	44842-1074
Country	:	US
Telephone Number	:	419-994-3071
Fax Number	:	419-994-4422

Provider Business Practice Location Address
First Line	:	631 N UNION ST
Second Line	:
City	:	LOUDONVILLE
State	:	OH
Zip	:	44842-1074
Country	:	US
Telephone Number	:	419-994-3071
Fax Number	:	419-994-4422

Authorized Official
Title or Position	:	OWNER/OPTOMETRIST
Name	:	DR. JENNIFER LYNN MILLER
Credential	:	O.D.
Telephone Number	:	419-994-3071

Provider Enumeration Date	:	12/04/2008
Last Update Date	:	12/04/2008

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