Provider Demographics
NPI:1356636179
Name:LONG, EUGENE
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9101 W SAHARA AVE STE 105-127
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-5772
Mailing Address - Country:US
Mailing Address - Phone:702-985-3943
Mailing Address - Fax:
Practice Address - Street 1:3674 N RANCHO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3110
Practice Address - Country:US
Practice Address - Phone:702-985-3943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner