Healthcare Provider Details

I. General information

NPI: 1629310685
Provider Name (Legal Business Name): ADAM J LONG ATC, CES, PES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2013
Last Update Date: 03/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 TAUGHANNOCK BLVD STE 5A
ITHACA NY
14850-3251
US

IV. Provider business mailing address

310 TAUGHANNOCK BLVD STE 5A
ITHACA NY
14850-3251
US

V. Phone/Fax

Practice location:
  • Phone: 607-252-3580
  • Fax: 607-252-3971
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number001751
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: