Healthcare Provider Details

I. General information

NPI: 1093062549
Provider Name (Legal Business Name): DR JOSEPH LONGNECKER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2012
Last Update Date: 10/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 E YORBA LINDA BLVD 306
PLACENTIA CA
92870-3728
US

IV. Provider business mailing address

5626 OBERLIN DR SUITE 110
SAN DIEGO CA
92121-1705
US

V. Phone/Fax

Practice location:
  • Phone: 714-577-9500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number20A3180
License Number StateCA

VIII. Authorized Official

Name: KENNY HEINE
Title or Position: VP OPS
Credential:
Phone: 858-964-1506