Provider Demographics
NPI:1679627459
Name:LONG, BILLY MIKEL (DC)
Entity Type:Individual
Prefix:
First Name:BILLY
Middle Name:MIKEL
Last Name:LONG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:BILLY
Other - Middle Name:
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:24009 VENTURA BLVD
Mailing Address - Street 2:STE 235
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-1423
Mailing Address - Country:US
Mailing Address - Phone:818-591-8847
Mailing Address - Fax:818-591-0549
Practice Address - Street 1:24007 VENTURA BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91302-2568
Practice Address - Country:US
Practice Address - Phone:818-591-8847
Practice Address - Fax:818-591-0549
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27936111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC27936OtherLICENSE #
CA202344792OtherTAX ID #
CAZZZ64988ZOtherBC-BS GROUP ID#
CAWDC27936AMedicare ID - Type UnspecifiedMEDICARE #
CAZZZ64988ZOtherBC-BS GROUP ID#