=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164767984
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONGE ENTERPRISES CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2012
-----------------------------------------------------
Last Update Date | 10/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 W NORTH ST
-----------------------------------------------------
City | KENDALLVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46755-1009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-347-1128
-----------------------------------------------------
Fax | 260-347-4948
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3409 N ANTHONY BLVD
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46805-2233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-484-0615
-----------------------------------------------------
Fax | 260-484-0616
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INSURANCE SPECIALIST
-----------------------------------------------------
Name | CARRIE M TRUEX
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 260-484-2691
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------