MEDICARE: KEAUNDRA LATRECEA 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	374U00000X	Home Health Aide	NA0008271107	TX

General Provider Information

NPI Number	:	1679086953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEAUNDRA LATRECEA LONG

Provider Business Mailing Address
First Line	:	13501 HOOPER RD TRLR 176
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77047-5078
Country	:	US
Telephone Number	:	281-747-9530
Fax Number	:

Provider Business Practice Location Address
First Line	:	13501 HOOPER RD TRLR 176
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77047-5078
Country	:	US
Telephone Number	:	281-747-9530
Fax Number	:

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

Provider Enumeration Date	:	11/09/2017
Last Update Date	:	11/09/2017

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Directions to “ KEAUNDRA LATRECEA LONG ” Practice Location

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