Healthcare Provider Details

I. General information

NPI: 1457907891
Provider Name (Legal Business Name): MEGHAN LONG DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4366 KUKUI GROVE ST STE 203
LIHUE HI
96766-2006
US

IV. Provider business mailing address

5801 S QUEBEC ST STE 100
GREENWOOD VILLAGE CO
80111-2010
US

V. Phone/Fax

Practice location:
  • Phone: 808-246-0144
  • Fax: 808-245-5148
Mailing address:
  • Phone: 303-887-0870
  • Fax: 303-770-0871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0016483
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4869
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: