Healthcare Provider Details

I. General information

NPI: 1629886627
Provider Name (Legal Business Name): RUSSELL K LONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2024
Last Update Date: 12/21/2024
Certification Date: 12/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 WILCREST DR APT 5
MEMPHIS TN
38134-5017
US

IV. Provider business mailing address

1805 WILCREST DR APT 5
MEMPHIS TN
38134-5017
US

V. Phone/Fax

Practice location:
  • Phone: 901-558-8302
  • Fax:
Mailing address:
  • Phone: 901-558-8302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: