Provider Demographics
NPI:1659441194
Name:LONG, WILLIE NATHANIEL III
Entity Type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:NATHANIEL
Last Name:LONG
Suffix:III
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 1:6214 BERKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77053-3448
Mailing Address - Country:US
Mailing Address - Phone:832-335-3228
Mailing Address - Fax:
Practice Address - Street 1:610 MURPHY RD STE 107
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-5926
Practice Address - Country:US
Practice Address - Phone:281-261-9616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32010589631332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies