MEDICARE: LONGE ENTERPRISES CORP

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	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1518202431
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONGE ENTERPRISES CORP

Provider Business Mailing Address
First Line	:	6709 W JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-6209
Country	:	US
Telephone Number	:	260-432-8409
Fax Number	:

Provider Business Practice Location Address
First Line	:	6709 W JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-6209
Country	:	US
Telephone Number	:	260-432-8409
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRUCE BOXBERGER
Credential	:
Telephone Number	:	260-423-9411

Provider Enumeration Date	:	12/04/2012
Last Update Date	:	04/17/2013

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Directions to “LONGE ENTERPRISES CORP ” Practice Location

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