Provider Demographics
NPI:1861020521
Name:LANGE, JON LEVI
Entity type:Individual
Prefix:
First Name:JON
Middle Name:LEVI
Last Name:LANGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 HARRIS ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:OH
Mailing Address - Zip Code:44446-2423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:721 HARRIS ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446-2423
Practice Address - Country:US
Practice Address - Phone:330-775-8267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty