MEDICARE: MRS. SIDNEY RAIN LONG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	226000000X	Recreational Therapist Assistant	1850	OK

General Provider Information

NPI Number	:	1679273833
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SIDNEY RAIN LONG

Provider Business Mailing Address
First Line	:	18750 RHINO RD
Second Line	:
City	:	SPIRO
State	:	OK
Zip	:	74959-4724
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8530 S 36TH TERR
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72908
Country	:	US
Telephone Number	:	918-436-9986
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2023
Last Update Date	:	03/07/2023

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