Provider Demographics
NPI:1144853326
Name:LONG, KRISTOPHER
Entity type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:
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 1:11406 PEDIGREE LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-1594
Mailing Address - Country:US
Mailing Address - Phone:704-724-4988
Mailing Address - Fax:
Practice Address - Street 1:11406 PEDIGREE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-1594
Practice Address - Country:US
Practice Address - Phone:704-724-4988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172A00000X
NC172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver