Basic Information
Provider Information | |||||||||
NPI: | 1821256025 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LANGE EYE CARE & ASSOC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3101 SW COLLEGE RD | ||||||||
Address2: |   | ||||||||
City: | OCALA | ||||||||
State: | FL | ||||||||
PostalCode: | 344748459 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3522373768 | ||||||||
FaxNumber: | 3522370561 | ||||||||
Practice Location | |||||||||
Address1: | 3968 SW ARCHER RD # W101 | ||||||||
Address2: |   | ||||||||
City: | GAINESVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 326082342 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3523766622 | ||||||||
FaxNumber: | 3522370561 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/26/2008 | ||||||||
LastUpdateDate: | 10/08/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LANGE | ||||||||
AuthorizedOfficialFirstName: | TAMIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | REGIONAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3522373768 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X |   | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 620668901 | 05 | FL |   | MEDICAID | 1326320001 | 01 | FL | DME | OTHER |