Provider Demographics
NPI:1407903453
Name:LONG, MARC A (DC)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:A
Last Name:LONG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:440 W BOUGHTON RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1892
Mailing Address - Country:US
Mailing Address - Phone:630-759-8989
Mailing Address - Fax:630-754-8685
Practice Address - Street 1:440 W BOUGHTON RD
Practice Address - Street 2:SUITE 102
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1892
Practice Address - Country:US
Practice Address - Phone:630-759-8989
Practice Address - Fax:630-754-8685
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL245340Medicare UPIN
IL09908149Medicare UPIN
IL133414183635Medicare UPIN
IL5095453Medicare UPIN
IL1781731Medicare UPIN