Healthcare Provider Details

I. General information

NPI: 1326104787
Provider Name (Legal Business Name): SUSAN LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W I-40 FRONTAGE RD STE 322
GALLUP NM
87301-3323
US

IV. Provider business mailing address

1300 W I-40 FRONTAGE RD STE 322
GALLUP NM
87301-3323
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-3030
  • Fax: 505-722-0367
Mailing address:
  • Phone: 505-722-3030
  • Fax: 505-722-0367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number03-037772-00-2
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: