Provider Demographics
NPI:1861931438
Name:LONG, VINCENT ANDREW
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:ANDREW
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 1:1157 LOUGHBOROUGH DR APT 1
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-1810
Mailing Address - Country:US
Mailing Address - Phone:209-769-2882
Mailing Address - Fax:
Practice Address - Street 1:1157 LOUGHBOROUGH DR APT 1
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-1810
Practice Address - Country:US
Practice Address - Phone:209-769-2882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer