Healthcare Provider Details

I. General information

NPI: 1386771673
Provider Name (Legal Business Name): KENT C LONG DC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 11/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4978 NORTHCUTT PL
DAYTON OH
45414-3840
US

IV. Provider business mailing address

4978 NORTHCUTT PL
DAYTON OH
45414-3840
US

V. Phone/Fax

Practice location:
  • Phone: 937-278-7246
  • Fax: 937-278-5640
Mailing address:
  • Phone: 937-278-7246
  • Fax: 937-278-5640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number1362
License Number StateOH

VIII. Authorized Official

Name: DR. KENT CHARLES LONG
Title or Position: OWNER
Credential: D.C.
Phone: 937-278-7246