Provider Demographics
NPI:1104818731
Name:LONG, LISA R (DC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:LONG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 E KARSCH BLVD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1203
Mailing Address - Country:US
Mailing Address - Phone:573-760-1515
Mailing Address - Fax:573-760-0817
Practice Address - Street 1:307 E KARSCH BLVD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1203
Practice Address - Country:US
Practice Address - Phone:573-760-1515
Practice Address - Fax:573-760-0817
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO5812111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO10410T002OtherCOVENTRY HEALTH
MOT2448OtherMERCY HEALTH PLANS
MO105957OtherBC/BS OF MISSOURI
MO10410T002OtherCOVENTRY HEALTH