Provider Demographics
NPI:1821656463
Name:LONGE, EYITAYO
Entity Type:Individual
Prefix:
First Name:EYITAYO
Middle Name:
Last Name:LONGE
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 129
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TX
Mailing Address - Zip Code:77328-0129
Mailing Address - Country:US
Mailing Address - Phone:832-969-8218
Mailing Address - Fax:
Practice Address - Street 1:24718 SCARLATTI CANTATA DR
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77493-3278
Practice Address - Country:US
Practice Address - Phone:832-969-8218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX841884628251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health