Provider Demographics
NPI:1629027107
Name:LONG, GREG S (DC)
Entity Type:Individual
Prefix:DR
First Name:GREG
Middle Name:S
Last Name:LONG
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 1:102 N. MAIN
Mailing Address - Street 2:
Mailing Address - City:VIBORG
Mailing Address - State:SD
Mailing Address - Zip Code:57070-0203
Mailing Address - Country:US
Mailing Address - Phone:605-766-2225
Mailing Address - Fax:605-766-3305
Practice Address - Street 1:102 N. MAIN
Practice Address - Street 2:
Practice Address - City:VIBORG
Practice Address - State:SD
Practice Address - Zip Code:57070-0203
Practice Address - Country:US
Practice Address - Phone:605-766-2225
Practice Address - Fax:605-766-3305
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06316111N00000X
SD900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAU72661Medicare UPIN
S101070Medicare PIN