Provider Demographics
NPI:1720833544
Name:LONG, GEORGE JR
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:
Last Name:LONG
Suffix:JR
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 1:329 FREEDOM AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44704-2319
Mailing Address - Country:US
Mailing Address - Phone:330-575-9480
Mailing Address - Fax:
Practice Address - Street 1:329 FREEDOM AVE NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44704-2319
Practice Address - Country:US
Practice Address - Phone:330-575-9480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide