Healthcare Provider Details

I. General information

NPI: 1972228641
Provider Name (Legal Business Name): TONY LONG RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2022
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 11TH ST RM 104
RAPID CITY SD
57701-3530
US

IV. Provider business mailing address

269 MINNESOTA ST
RAPID CITY SD
57701-6205
US

V. Phone/Fax

Practice location:
  • Phone: 605-791-6346
  • Fax:
Mailing address:
  • Phone: 605-393-5978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License NumberR039099
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: