Healthcare Provider Details

I. General information

NPI: 1285337212
Provider Name (Legal Business Name): KENNETH LONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 E MARKET ST STE 3
LIMA OH
45801-4535
US

IV. Provider business mailing address

311 E MARKET ST STE 3
LIMA OH
45801-4535
US

V. Phone/Fax

Practice location:
  • Phone: 419-222-4474
  • Fax:
Mailing address:
  • Phone: 419-222-4474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: