Provider Demographics
NPI:1508540519
Name:LONG, KHALIL RAPISURA
Entity Type:Individual
Prefix:
First Name:KHALIL
Middle Name:RAPISURA
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 1:11511 MILFORD HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-4112
Mailing Address - Country:US
Mailing Address - Phone:714-345-1876
Mailing Address - Fax:
Practice Address - Street 1:25455 MEDICAL CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-1500
Practice Address - Country:US
Practice Address - Phone:951-297-7017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21CA1392243U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes243U00000XTechnologists, Technicians & Other Technical Service ProvidersRadiology Practitioner Assistant