Healthcare Provider Details

I. General information

NPI: 1700070083
Provider Name (Legal Business Name): LONG SIGHT, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 08/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 CAMPBELL AVE SE
ROANOKE VA
24011-1404
US

IV. Provider business mailing address

4251 TWIN MOUNTAIN DR
VINTON VA
24179-1021
US

V. Phone/Fax

Practice location:
  • Phone: 540-982-7890
  • Fax: 540-982-7891
Mailing address:
  • Phone: 540-875-8036
  • Fax: 888-840-8937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001106
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number0618001106
License Number StateVA

VIII. Authorized Official

Name: DR. JILDA EDEAN LONG
Title or Position: OPTOMETRIST/ OWNER
Credential: O.D.
Phone: 540-875-8036