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General NPI Number Information
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NPI Number | 1265656524
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Entity Type | Individual
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Provider Name | BRANDI LA'SHELLE LONG O.D.
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Gender | Female
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Dates
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Enumeration Date | 04/11/2007
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Last Update Date | 06/03/2016
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Provider Practice Location Address
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Address Line | 547 W CHURCH ST WAL-MART VISION CENTER
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City | LEXINGTON
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State | TN
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Zip | 38351-1703
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Country | US
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Telephone | 731-450-0120
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Fax | 731-968-5595
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Provider Business Mailing Address
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Address Line | 9 BASCOM RD
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City | JACKSON
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State | TN
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Zip | 38305-8800
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Country | US
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Telephone | 731-267-0040
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Fax | 731-427-7657
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2546
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License Number State | TN
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