Provider Demographics
NPI:1972836310
Name:LONGE OPTICAL
Entity Type:Organization
Organization Name:LONGE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:C
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-347-1128
Mailing Address - Street 1:625 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:KENDALLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46755-1009
Mailing Address - Country:US
Mailing Address - Phone:260-347-1128
Mailing Address - Fax:260-347-4948
Practice Address - Street 1:625 W NORTH ST
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-1009
Practice Address - Country:US
Practice Address - Phone:260-347-1128
Practice Address - Fax:260-347-4948
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LONGE OPTICAL NORTH INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-17
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100173460Medicaid