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General NPI Number Information
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NPI Number | 1770667917
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Entity Type | Organization
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Legal Business Name | LONGE OPTICAL
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Dates
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Enumeration Date | 10/24/2006
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Last Update Date | 04/22/2009
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Provider Practice Location Address
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Address Line | 7625 SOUTHTOWN CROSSING
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City | FORT WAYNE
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State | IN
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Zip | 46816-2506
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Country | US
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Telephone | 260-447-3583
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Fax | 260-441-8276
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Provider Business Mailing Address
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Address Line | 7625 SOUTHTOWN CROSSING
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City | FORT WAYNE
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State | IN
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Zip | 46816-2506
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Country | US
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Telephone | 260-447-3583
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Fax | 260-441-8276
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Authorized Official
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Title or Position | OWNER
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Name | MR. LARRY KENSILL
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Credential |
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Telephone | 260-484-2691
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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