Provider Demographics
NPI:1336277078
Name:LONGSHORE, GARY D (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:D
Last Name:LONGSHORE
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 1:12044 BALD HILL RD SE
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-9664
Mailing Address - Country:US
Mailing Address - Phone:360-458-9812
Mailing Address - Fax:
Practice Address - Street 1:12044 BALD HILL RD SE
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-9664
Practice Address - Country:US
Practice Address - Phone:360-943-4113
Practice Address - Fax:360-455-4112
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH3400111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA188260OtherL&I ID NUMBER
WA609947OtherACN ACCOUNT NUMBER
WA609947OtherACN ACCOUNT NUMBER