MEDICARE: DARNETTA MAE LONG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247200000X	Other Technician

General Provider Information

NPI Number	:	1306390372
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARNETTA MAE LONG

Provider Business Mailing Address
First Line	:	19154 DEQUINDRE ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48234-1208
Country	:	US
Telephone Number	:	313-622-9005
Fax Number	:

Provider Business Practice Location Address
First Line	:	19154 DEQUINDRE ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48234-1208
Country	:	US
Telephone Number	:	313-622-9005
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2016
Last Update Date	:	08/08/2016

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Directions to “ DARNETTA MAE LONG ” Practice Location

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