Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 1101 002062 | VA |
NPI | 1194861328 |
---|---|
Provider Name | Robert W Long |
First Address | Martinsville, VA 24112-1841 |
Second Address | Martinsville, VA 24112-1841 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/01/2007 |
Last Update Date | 08/07/2007 |