Healthcare Provider Details

I. General information

NPI: 1356684005
Provider Name (Legal Business Name): MRS. CHRISTINE DIANNE LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHRISTIE DIANNE BEAUCHAMP

II. Dates (important events)

Enumeration Date: 04/01/2013
Last Update Date: 08/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 RICHLAND AVE
CERES CA
95307-4562
US

IV. Provider business mailing address

1904 RICHLAND AVE
CERES CA
95307-4562
US

V. Phone/Fax

Practice location:
  • Phone: 209-541-2121
  • Fax:
Mailing address:
  • Phone: 209-541-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: