Healthcare Provider Details

I. General information

NPI: 1720484926
Provider Name (Legal Business Name): TINA MARIE LONG RRT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2014
Last Update Date: 11/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DR
COLUMBIA MO
65201-5276
US

IV. Provider business mailing address

1 HOSPITAL DR
COLUMBIA MO
65201-5276
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-4141
  • Fax:
Mailing address:
  • Phone: 573-882-4141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number2012016357
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: