=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326104787
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN LONG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 W I-40 FRONTAGE RD STE 322
-----------------------------------------------------
City | GALLUP
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87301-3323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-722-3030
-----------------------------------------------------
Fax | 505-722-0367
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 W I-40 FRONTAGE RD STE 322
-----------------------------------------------------
City | GALLUP
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87301-3323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-722-3030
-----------------------------------------------------
Fax | 505-722-0367
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 03-037772-00-2
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------