Provider Demographics
NPI:1972514826
Name:LONG, TIMOTHY (DC)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2979 N CANNON BLVD
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083-9125
Mailing Address - Country:US
Mailing Address - Phone:704-855-3728
Mailing Address - Fax:704-855-4700
Practice Address - Street 1:2979 N CANNON BLVD
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083-9125
Practice Address - Country:US
Practice Address - Phone:704-855-3728
Practice Address - Fax:704-855-4700
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2109111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7908599Medicaid
NC2448802Medicare PIN
NCU51883Medicare UPIN