Healthcare Provider Details

I. General information

NPI: 1679273833
Provider Name (Legal Business Name): MRS. SIDNEY RAIN LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2023
Last Update Date: 03/07/2023
Certification Date: 03/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8530 S 36TH TERR
FORT SMITH AR
72908
US

IV. Provider business mailing address

18750 RHINO RD
SPIRO OK
74959-4724
US

V. Phone/Fax

Practice location:
  • Phone: 918-436-9986
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226000000X
TaxonomyRecreational Therapist Assistant
License Number1850
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: