Healthcare Provider Details

I. General information

NPI: 1689349078
Provider Name (Legal Business Name): CAROLYN DIANE LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

834 E 320 N
SALEM UT
84653-5535
US

IV. Provider business mailing address

834 E 320 N
SALEM UT
84653-5535
US

V. Phone/Fax

Practice location:
  • Phone: 801-358-9166
  • Fax:
Mailing address:
  • Phone: 801-358-9166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: