Provider Demographics
NPI:1497433080
Name:LONGDONG, LOVELY
Entity Type:Individual
Prefix:
First Name:LOVELY
Middle Name:
Last Name:LONGDONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25573 LANE ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2412
Mailing Address - Country:US
Mailing Address - Phone:909-556-5166
Mailing Address - Fax:
Practice Address - Street 1:32819 YUCAIPA BLVD STE 3
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-1944
Practice Address - Country:US
Practice Address - Phone:909-797-9010
Practice Address - Fax:909-797-9046
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50392225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant