Provider Demographics
NPI:1558326652
Name:LONG, MIKE DENNIS (MED, ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:MIKE
Middle Name:DENNIS
Last Name:LONG
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Gender:M
Credentials:MED, ATC, CSCS
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Mailing Address - Street 1:500 CLINIC DR
Mailing Address - Street 2:TROVER FOUNDATION SPORTS MEDICINE
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-4991
Mailing Address - Country:US
Mailing Address - Phone:270-707-3387
Mailing Address - Fax:270-707-3361
Practice Address - Street 1:500 CLINIC DR
Practice Address - Street 2:TROVER FOUNDATION SPORTS MEDICINE
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-4991
Practice Address - Country:US
Practice Address - Phone:270-707-3387
Practice Address - Fax:270-707-3361
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
KYAT3572255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer