Provider Demographics
NPI:1720650443
Name:LONGBRAKE, DILLON REID (ATHLETIC TRAINER)
Entity type:Individual
Prefix:MR
First Name:DILLON
Middle Name:REID
Last Name:LONGBRAKE
Suffix:
Gender:M
Credentials:ATHLETIC TRAINER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 NE 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PERKINS
Mailing Address - State:OK
Mailing Address - Zip Code:74059-3016
Mailing Address - Country:US
Mailing Address - Phone:405-338-8938
Mailing Address - Fax:
Practice Address - Street 1:100 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-5207
Practice Address - Country:US
Practice Address - Phone:405-974-5239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer