Provider Demographics
NPI:1376864629
Name:LONG, GRANT B (DPT)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:B
Last Name:LONG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:4999 SKYLINE RD S
Practice Address - Street 2:SUITE 90
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-2878
Practice Address - Country:US
Practice Address - Phone:503-566-7700
Practice Address - Fax:503-566-7703
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R105769Medicare PIN