Provider Demographics
NPI:1396413555
Name:LONG, MATTHEW D
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:D
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 1:193 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:MARLINTON
Mailing Address - State:WV
Mailing Address - Zip Code:24954-1232
Mailing Address - Country:US
Mailing Address - Phone:304-646-0570
Mailing Address - Fax:
Practice Address - Street 1:193 4TH AVE
Practice Address - Street 2:
Practice Address - City:MARLINTON
Practice Address - State:WV
Practice Address - Zip Code:24954-1232
Practice Address - Country:US
Practice Address - Phone:304-646-0570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide