Provider Demographics
NPI:1376726687
Name:OMURA-LONG, TOSHIO JAMES (LAC)
Entity Type:Individual
Prefix:MR
First Name:TOSHIO
Middle Name:JAMES
Last Name:OMURA-LONG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:MR
Other - First Name:WESLEY
Other - Middle Name:DOUGLAS
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:1230 SE MORRISON ST
Mailing Address - Street 2:#201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2453
Mailing Address - Country:US
Mailing Address - Phone:503-453-6995
Mailing Address - Fax:
Practice Address - Street 1:2538 NE BROADWAY ST
Practice Address - Street 2:SUITE C
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1872
Practice Address - Country:US
Practice Address - Phone:503-453-6995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-10
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00964171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist