Healthcare Provider Details

I. General information

NPI: 1265587729
Provider Name (Legal Business Name): MICHAEL LEE LONGENECKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12033 AGENCY RD
PARKER AZ
85344-7718
US

IV. Provider business mailing address

833 W MEADE LN
FLAGSTAFF AZ
86001-1210
US

V. Phone/Fax

Practice location:
  • Phone: 928-669-3380
  • Fax: 928-669-3377
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number36777
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: