MEDICARE: MRS. LATONYA RENEE 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	1744P3200X	Prosthetics Case Management	32WG06189000	NJ

General Provider Information

NPI Number	:	1750815288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LATONYA RENEE LONG

Provider Business Mailing Address
First Line	:	613 WHITE HORSE PIKE
Second Line	:
City	:	HADDON TOWNSHIP
State	:	NJ
Zip	:	08107-1219
Country	:	US
Telephone Number	:	856-240-1095
Fax Number	:

Provider Business Practice Location Address
First Line	:	613 WHITE HORSE PIKE
Second Line	:
City	:	HADDON TOWNSHIP
State	:	NJ
Zip	:	08107-1219
Country	:	US
Telephone Number	:	856-240-1095
Fax Number	:

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

Provider Enumeration Date	:	04/11/2017
Last Update Date	:	04/11/2017

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