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General NPI Number Information
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NPI Number | 1659441194
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Entity Type | Individual
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Provider Name | MR. WILLIE NATHANIEL LONG III
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Gender | Male
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Dates
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Enumeration Date | 11/09/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 610 MURPHY RD STE 107
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City | STAFFORD
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State | TX
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Zip | 77477-5926
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Country | US
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Telephone | 281-261-9616
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Fax |
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Provider Business Mailing Address
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Address Line | 6214 BERKRIDGE DR
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City | HOUSTON
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State | TX
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Zip | 77053-3448
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Country | US
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Telephone | 832-335-3228
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Fax |
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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 | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 32010589631
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License Number State | TX
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