Provider Demographics
NPI:1508341272
Name:LONG, LORI L
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:L
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6864
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-6864
Mailing Address - Country:US
Mailing Address - Phone:228-861-3274
Mailing Address - Fax:
Practice Address - Street 1:698 MICHELLE DR
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-4504
Practice Address - Country:US
Practice Address - Phone:228-861-3274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-28
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS59874953418M1110X, 344600000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No3418M1110XTransportation ServicesMilitary/U.S. Coast Guard TransportMilitary or U.S. Coast Guard Ambulance, Ground Transport
No344600000XTransportation ServicesTaxi