Provider Demographics
NPI:1356338263
Name:LONGO, MELISSA ANN (DC)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:ANN
Last Name:LONGO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:LONGO-ROYER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:500 W CENTRAL RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-2347
Mailing Address - Country:US
Mailing Address - Phone:847-259-6605
Mailing Address - Fax:847-259-8071
Practice Address - Street 1:500 W CENTRAL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-2347
Practice Address - Country:US
Practice Address - Phone:847-259-6605
Practice Address - Fax:847-259-8071
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008169111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL552960Medicare ID - Type Unspecified
ILU67049Medicare UPIN