Provider Demographics
NPI:1497088702
Name:LONGE OPTICAL NORTH INC
Entity Type:Organization
Organization Name:LONGE OPTICAL NORTH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBY
Authorized Official - Middle Name:L
Authorized Official - Last Name:QUARRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-925-5944
Mailing Address - Street 1:650 N GRANDSTAFF DR
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46706-1661
Mailing Address - Country:US
Mailing Address - Phone:260-925-5944
Mailing Address - Fax:260-925-5944
Practice Address - Street 1:650 N GRANDSTAFF DR
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-1661
Practice Address - Country:US
Practice Address - Phone:260-925-5944
Practice Address - Fax:260-925-5944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-18
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100173460DMedicaid