Provider Demographics
NPI:1275095101
Name:LONG, TYSON BENJAMIN (DC)
Entity Type:Individual
Prefix:DR
First Name:TYSON
Middle Name:BENJAMIN
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 1:1096 EASTLAND DR N STE 300
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-8970
Mailing Address - Country:US
Mailing Address - Phone:208-537-7246
Mailing Address - Fax:
Practice Address - Street 1:1096 EASTLAND DR N STE 300
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-8970
Practice Address - Country:US
Practice Address - Phone:208-537-7246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1916111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor