=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700070083
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONG SIGHT, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2007
-----------------------------------------------------
Last Update Date | 08/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22 CAMPBELL AVE SE
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24011-1404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-982-7890
-----------------------------------------------------
Fax | 540-982-7891
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4251 TWIN MOUNTAIN DR
-----------------------------------------------------
City | VINTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24179-1021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-875-8036
-----------------------------------------------------
Fax | 888-840-8937
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST/ OWNER
-----------------------------------------------------
Name | DR. JILDA EDEAN LONG
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 540-875-8036
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 0618001106
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 0618001106
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------