Provider Demographics
NPI:1336221589
Name:LONG, J BRAD
Entity type:Individual
Prefix:DR
First Name:J
Middle Name:BRAD
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 INDUSTRY ROAD
Mailing Address - Street 2:SUITE 34
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40505
Mailing Address - Country:US
Mailing Address - Phone:859-233-3248
Mailing Address - Fax:859-233-3250
Practice Address - Street 1:1020 INDUSTRY ROAD
Practice Address - Street 2:SUITE 34
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505
Practice Address - Country:US
Practice Address - Phone:859-233-3248
Practice Address - Fax:859-233-3250
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3866111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
6046901Medicare ID - Type Unspecified