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NPI Code Detail

MEDICARE: SHANNON OLIVIA LONG PT, DPT

MEDICARE: SHANNON OLIVIA LONG PT, 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 Therapist291794CA

General Provider Information

NPI Number : 1992299358
Entity Type Code : Individual
Provider Name (Legal Business Name) : SHANNON OLIVIA LONG PT, DPT
Provider Business Mailing Address
First Line : 10780 SANTA MONICA BLVD STE 405
Second Line :
City : LOS ANGELES
State : CA
Zip : 90025-7655
Country : US
Telephone Number : 310-234-0300
Fax Number : 310-234-0304
Provider Business Practice Location Address
First Line : 10780 SANTA MONICA BLVD STE 405
Second Line :
City : LOS ANGELES
State : CA
Zip : 90025-7655
Country : US
Telephone Number : 310-234-0300
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/19/2018
Last Update Date : 09/14/2018

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