Provider Demographics
NPI:1336485051
Name:LONG HEALTH FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:LONG HEALTH FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:361-935-9250
Mailing Address - Street 1:PO BOX 5099
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77903-5099
Mailing Address - Country:US
Mailing Address - Phone:361-579-1319
Mailing Address - Fax:361-579-1317
Practice Address - Street 1:2710 HOSPITAL DR
Practice Address - Street 2:SUITE 108
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-5701
Practice Address - Country:US
Practice Address - Phone:361-579-1319
Practice Address - Fax:361-579-1317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-27
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX595695363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty