1174812473 NPI number — CASEY JEANNE LONG D.C.

Table of content: CASEY JEANNE LONG D.C. (NPI 1174812473)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174812473 NPI number — CASEY JEANNE LONG D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LONG
Provider First Name:
CASEY
Provider Middle Name:
JEANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CESSNA
Provider Other First Name:
CASEY
Provider Other Middle Name:
JEANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174812473
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 W COLLEGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WITTENBERG
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54499-9196
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-253-2239
Provider Business Mailing Address Fax Number:
715-253-3331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 S 32ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUSAU
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54401-3958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-848-1741
Provider Business Practice Location Address Fax Number:
715-848-2225
Provider Enumeration Date:
04/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111NS0005X , with the licence number:  5509 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 4772-012 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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