Provider Demographics
NPI:1235487083
Name:LONG, RYAN M (DPT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:M
Last Name:LONG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:885 CANARIOS CT STE 110
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-7877
Mailing Address - Country:US
Mailing Address - Phone:619-656-5102
Mailing Address - Fax:619-656-5143
Practice Address - Street 1:320 BROADWAY STE 2
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-3502
Practice Address - Country:US
Practice Address - Phone:619-447-7774
Practice Address - Fax:619-447-7779
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39193225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT39193OtherPHYSICAL THERAPIST LICENSE
CAGX219ZMedicare PIN