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NPI Code Detail

MEDICARE: GRANT B LONG DPT

MEDICARE: GRANT B LONG DPT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist

General Provider Information

NPI Number : 1376864629
Entity Type Code : Individual
Provider Name (Legal Business Name) : GRANT B LONG DPT
Provider Business Mailing Address
First Line : 790 REMINGTON BLVD
Second Line :
City : BOLINGBROOK
State : IL
Zip : 60440-4909
Country : US
Telephone Number : 630-296-2223
Fax Number : 630-759-9510
Provider Business Practice Location Address
First Line : 4999 SKYLINE RD S
Second Line : SUITE 90
City : SALEM
State : OR
Zip : 97306-2878
Country : US
Telephone Number : 503-566-7700
Fax Number : 503-566-7703
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/21/2010
Last Update Date : 06/23/2016

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