Provider Demographics
NPI:1245439231
Name:LONG FAMILY EYE CARE P.C.
Entity type:Organization
Organization Name:LONG FAMILY EYE CARE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:S
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:812-332-5090
Mailing Address - Street 1:660 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2527
Mailing Address - Country:US
Mailing Address - Phone:812-332-5090
Mailing Address - Fax:812-332-5092
Practice Address - Street 1:660 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2527
Practice Address - Country:US
Practice Address - Phone:812-332-5090
Practice Address - Fax:812-332-5092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002828B152W00000X
IN18002841B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN3852570001Medicare NSC
INU64260Medicare UPIN
INU64638Medicare UPIN