Provider Demographics
NPI:1992039929
Name:LONGE OPTICAL NORTH INC.
Entity Type:Organization
Organization Name:LONGE OPTICAL NORTH INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:KENSILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-484-2691
Mailing Address - Street 1:10240 COLDWATER RD.
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825
Mailing Address - Country:US
Mailing Address - Phone:260-484-2691
Mailing Address - Fax:260-484-0616
Practice Address - Street 1:10240 COLDWATER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-2035
Practice Address - Country:US
Practice Address - Phone:260-497-8626
Practice Address - Fax:260-484-8486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-23
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100173460FMedicaid
IN100173460FMedicaid