Provider Demographics
NPI:1548593072
Name:LONGE OPTICAL- NORTH INC.
Entity Type:Organization
Organization Name:LONGE OPTICAL- NORTH INC.
Other - Org Name:LONGE OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:STORE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:BAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-432-8409
Mailing Address - Street 1:5721 COVENTRY LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7146
Mailing Address - Country:US
Mailing Address - Phone:260-432-8409
Mailing Address - Fax:260-432-8506
Practice Address - Street 1:5721 COVENTRY LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-7146
Practice Address - Country:US
Practice Address - Phone:260-432-8409
Practice Address - Fax:260-432-8506
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LONGE OPTICAL- NORTH INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-16
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100173460CMedicaid
054683005Medicare PIN
IN100173460CMedicaid