Provider Demographics
NPI:1104402890
Name:LONG, CLINTON LEVI
Entity type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:LEVI
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 1:14603 EDENGLEN DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77049-3810
Mailing Address - Country:US
Mailing Address - Phone:346-232-2419
Mailing Address - Fax:
Practice Address - Street 1:14603 EDENGLEN DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77049-3810
Practice Address - Country:US
Practice Address - Phone:281-745-0828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28641704343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)