Provider Demographics
NPI:1609386721
Name:LONG, JOHNNY RAY
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:RAY
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:PO BOX 8144
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88355-8144
Mailing Address - Country:US
Mailing Address - Phone:575-973-1417
Mailing Address - Fax:
Practice Address - Street 1:102 CORRAL RD
Practice Address - Street 2:
Practice Address - City:RUIDOSO DOWNS
Practice Address - State:NM
Practice Address - Zip Code:88346-9492
Practice Address - Country:US
Practice Address - Phone:575-973-1417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle