Healthcare Provider Details

I. General information

NPI: 1235487083
Provider Name (Legal Business Name): RYAN M LONG DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 BROADWAY STE 2
CHULA VISTA CA
91910-3502
US

IV. Provider business mailing address

885 CANARIOS CT STE 110
CHULA VISTA CA
91910-7877
US

V. Phone/Fax

Practice location:
  • Phone: 619-447-7774
  • Fax: 619-447-7779
Mailing address:
  • Phone: 619-656-5102
  • Fax: 619-656-5143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number39193
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: