Provider Demographics
NPI:1093964124
Name:LONG CHIROPRACTIC, P. A.
Entity Type:Organization
Organization Name:LONG CHIROPRACTIC, P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:MILES
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:228-594-1181
Mailing Address - Street 1:2541 PASS RD
Mailing Address - Street 2:STE H
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-2106
Mailing Address - Country:US
Mailing Address - Phone:228-594-1181
Mailing Address - Fax:228-594-1920
Practice Address - Street 1:2541 PASS RD
Practice Address - Street 2:STE H
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2106
Practice Address - Country:US
Practice Address - Phone:228-594-1181
Practice Address - Fax:228-594-1920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS110261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115873Medicaid
MS00115873Medicaid