Provider Demographics
NPI:1457507147
Name:DAVID R. LONG D.C. P.A.
Entity Type:Organization
Organization Name:DAVID R. LONG D.C. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-736-1976
Mailing Address - Street 1:497 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-7441
Mailing Address - Country:US
Mailing Address - Phone:208-736-1976
Mailing Address - Fax:208-736-1986
Practice Address - Street 1:497 EASTLAND DR
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-7441
Practice Address - Country:US
Practice Address - Phone:208-736-1976
Practice Address - Fax:208-736-1986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-621111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000010020543OtherBLUE SHIELD
C6210OtherBLUE CROSS
000010020543OtherBLUE SHIELD