Provider Demographics
NPI:1821486325
Name:LONG, MERRILL
Entity Type:Individual
Prefix:
First Name:MERRILL
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 WELLER CT
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-4606
Mailing Address - Country:US
Mailing Address - Phone:925-300-7047
Mailing Address - Fax:
Practice Address - Street 1:1444 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5319
Practice Address - Country:US
Practice Address - Phone:925-939-6262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC30761111N00000X
CAAC14804171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No111N00000XChiropractic ProvidersChiropractor