Basic Information
| Provider Information | |||||||||
| NPI: | 1013184357 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOOD LOOKS EYEWEAR INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 BRANDT DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CRANBERRY TWP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 160666437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247725474 | ||||||||
| FaxNumber: | 7247725423 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 FREEPORT RD | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152383103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4127821919 | ||||||||
| FaxNumber: | 4127821199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2008 | ||||||||
| LastUpdateDate: | 07/03/2013 | ||||||||
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| AuthorizedOfficialLastName: | CHRISTIE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | CLARK | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4127821919 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | MD037014E | PA | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | GL000165292 | 01 | PA | BLUE SHIELD | OTHER | 0017381360006 | 05 | PA | MEDICAID |