MEDICARE: LONGE OPTICAL NORTH INC.

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	:	1992039929
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONGE OPTICAL NORTH INC.

Provider Business Mailing Address
First Line	:	10240 COLDWATER RD.
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825
Country	:	US
Telephone Number	:	260-484-2691
Fax Number	:	260-484-0616

Provider Business Practice Location Address
First Line	:	10240 COLDWATER RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-2035
Country	:	US
Telephone Number	:	260-497-8626
Fax Number	:	260-484-8486

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

Provider Enumeration Date	:	09/23/2009
Last Update Date	:	10/07/2009

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