Provider Demographics
NPI:1144395062
Name:LONG, MONTY CORNELL (DC)
Entity Type:Individual
Prefix:DR
First Name:MONTY
Middle Name:CORNELL
Last Name:LONG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:TN
Mailing Address - Zip Code:37327-0936
Mailing Address - Country:US
Mailing Address - Phone:423-949-5599
Mailing Address - Fax:423-949-5585
Practice Address - Street 1:86 FRONTAGE RD.
Practice Address - Street 2:
Practice Address - City:DUNLAP
Practice Address - State:TN
Practice Address - Zip Code:37327
Practice Address - Country:US
Practice Address - Phone:423-949-5599
Practice Address - Fax:423-949-5585
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1810111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4074923OtherBCBST #
TN7003292OtherAETNA PROVIDER #
TN3971982Medicare ID - Type Unspecified
TN7003292OtherAETNA PROVIDER #