1396798963 NPI number — LONGE OPTICAL INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396798963 NPI number — LONGE OPTICAL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LONGE OPTICAL INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396798963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
01/16/2007
NPI Reactivation Date:
03/28/2008

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3409 N ANTHONY BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FT. WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-484-2691
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3409 N ANTHONY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-484-2691
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAVENPORT
Authorized Official First Name:
MARTHA
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
260-347-1128

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100173460 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100173460E , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com