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General NPI Number Information
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NPI Number | 1821643966
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Entity Type | Organization
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Legal Business Name | LONG LEGACY CHIROPRACTIC
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Dates
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Enumeration Date | 08/06/2019
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Last Update Date | 08/06/2019
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Provider Practice Location Address
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Address Line | 1096 EASTLAND DR N STE 300
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City | TWIN FALLS
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State | ID
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Zip | 83301-8970
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Country | US
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Telephone | 208-537-7246
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Fax |
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Provider Business Mailing Address
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Address Line | 1096 EASTLAND DR N STE 300
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City | TWIN FALLS
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State | ID
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Zip | 83301-8970
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Country | US
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Telephone | 208-537-7246
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. TY BENJAMIN LONG
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Credential | DC
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Telephone | 208-537-7246
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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