MEDICARE: LONGE OPTICAL

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770667917
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONGE OPTICAL

Provider Business Mailing Address
First Line	:	7625 SOUTHTOWN CROSSING
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46816-2506
Country	:	US
Telephone Number	:	260-447-3583
Fax Number	:	260-441-8276

Provider Business Practice Location Address
First Line	:	7625 SOUTHTOWN CROSSING
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46816-2506
Country	:	US
Telephone Number	:	260-447-3583
Fax Number	:	260-441-8276

Authorized Official
Title or Position	:	OWNER
Name	:	MR. LARRY KENSILL
Credential	:
Telephone Number	:	260-484-2691

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	04/22/2009

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Directions to “LONGE OPTICAL ” Practice Location

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