Provider Demographics
NPI:1346284510
Name:LONG, VANCE ALLEN (DC)
Entity Type:Individual
Prefix:
First Name:VANCE
Middle Name:ALLEN
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 1:1122 WALNUT DR
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-2353
Mailing Address - Country:US
Mailing Address - Phone:580-223-8200
Mailing Address - Fax:580-223-8212
Practice Address - Street 1:1122 WALNUT DR
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2353
Practice Address - Country:US
Practice Address - Phone:580-223-8200
Practice Address - Fax:580-223-8212
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3340111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK800522128Medicare UPIN
OKP00150093Medicare PIN