Healthcare Provider Details

I. General information

NPI: 1184541559
Provider Name (Legal Business Name): BRYCE LONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1082 FAIRVIEW AVE APT I1
BOWLING GREEN OH
43402-1274
US

IV. Provider business mailing address

1082 FAIRVIEW AVE APT I1
BOWLING GREEN OH
43402-1274
US

V. Phone/Fax

Practice location:
  • Phone: 614-715-0333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: