Provider Demographics
NPI:1619043270
Name:LONG, RYAN THOMAS (DC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:THOMAS
Last Name:LONG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:RYAN
Other - Middle Name:THOMAS
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:136 KISSANE AVE STE C
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-1895
Mailing Address - Country:US
Mailing Address - Phone:810-227-1113
Mailing Address - Fax:810-227-8087
Practice Address - Street 1:136 KISSANE AVE STE C
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-1895
Practice Address - Country:US
Practice Address - Phone:810-227-1113
Practice Address - Fax:810-227-8087
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008418111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950D750380Medicare UPIN
MION32260MCMedicare ID - Type Unspecified