Provider Demographics
NPI:1629886627
Name:LONG, RUSSELL K
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:K
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 1:1805 WILCREST DR APT 5
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38134-5017
Mailing Address - Country:US
Mailing Address - Phone:901-558-8302
Mailing Address - Fax:
Practice Address - Street 1:1805 WILCREST DR APT 5
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-5017
Practice Address - Country:US
Practice Address - Phone:901-558-8302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-21
Last Update Date:2024-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist