Provider Demographics
NPI:1396019006
Name:VAN, LONG (DC)
Entity Type:Individual
Prefix:
First Name:LONG
Middle Name:
Last Name:VAN
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 1:6947 MERRILL RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-2684
Mailing Address - Country:US
Mailing Address - Phone:904-743-2222
Mailing Address - Fax:904-743-3087
Practice Address - Street 1:6025 WINDING BRIDGE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-1443
Practice Address - Country:US
Practice Address - Phone:904-305-3785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-27
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10561111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor