Healthcare Provider Details

I. General information

NPI: 1801368048
Provider Name (Legal Business Name): MARY LONG DACM, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2018
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 ATLANTIC AVE STE 5
LONG BEACH CA
90807-2833
US

IV. Provider business mailing address

PO BOX 40327
DOWNEY CA
90239-1327
US

V. Phone/Fax

Practice location:
  • Phone: 562-888-9933
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number18298
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: