Basic Information
| Provider Information | |||||||||
| NPI: | 1568761658 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | LONG | ||||||||
| FirstName: | TRACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9499 W CHARLESTON BLVD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891177150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029339393 | ||||||||
| FaxNumber: | 7029336789 | ||||||||
| Practice Location | |||||||||
| Address1: | 9499 W CHARLESTON BLVD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891177150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029339393 | ||||||||
| FaxNumber: | 7029336789 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2011 | ||||||||
| LastUpdateDate: | 03/15/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
No ID Information.