=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518207604
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAMES T. LONG, M.D., PH.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2013
-----------------------------------------------------
Last Update Date | 02/26/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 650 MORENO AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90049-4831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-395-7392
-----------------------------------------------------
Fax | 310-394-7902
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 650 MORENO AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90049-4831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-395-7392
-----------------------------------------------------
Fax | 310-394-7902
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JAMES T. LONG
-----------------------------------------------------
Credential | M.D., PH.D.
-----------------------------------------------------
Telephone | 310-395-7392
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | G19016
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------