Provider Demographics
NPI:1285678441
Name:LONG, CHARLES A (PT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:LONG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GWINNER
Mailing Address - State:ND
Mailing Address - Zip Code:58040-4001
Mailing Address - Country:US
Mailing Address - Phone:701-678-2244
Mailing Address - Fax:701-678-2210
Practice Address - Street 1:11 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GWINNER
Practice Address - State:ND
Practice Address - Zip Code:58040-4001
Practice Address - Country:US
Practice Address - Phone:701-678-2244
Practice Address - Fax:701-678-2210
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND580225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND51075Medicaid