Provider Demographics
NPI:1871317545
Name:DELONG, LUKE
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:
Last Name:DELONG
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:PO BOX 30516
Mailing Address - Street 2:DEPT 5300
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48909
Mailing Address - Country:US
Mailing Address - Phone:616-608-9979
Mailing Address - Fax:
Practice Address - Street 1:9028 N RODGERS CT SE STE J
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-7786
Practice Address - Country:US
Practice Address - Phone:616-891-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501303533225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501303533OtherSTATE LICENSE