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General NPI Number Information
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NPI Number | 1871726562
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Entity Type | Organization
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Legal Business Name | JAMES A. LONG, II O.D. INC
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Dates
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Enumeration Date | 08/27/2009
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Last Update Date | 08/27/2009
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Provider Practice Location Address
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Address Line | 1221 MEDICAL PARK DR
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City | FORT WAYNE
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State | IN
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Zip | 46825-5887
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Country | US
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Telephone | 260-484-2720
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Fax | 260-471-3488
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Provider Business Mailing Address
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Address Line | 1221 MEDICAL PARK DR
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City | FORT WAYNE
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State | IN
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Zip | 46825-5887
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Country | US
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Telephone | 260-448-4272
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Fax | 260-471-3488
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. JAMES A LONG II
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Credential | OD
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Telephone | 260-484-2720
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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 | 18001507
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License Number State | IN
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