Provider Demographics
NPI:1821234097
Name:LONGENECKER
Entity Type:Organization
Organization Name:LONGENECKER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, LONGENECKER VISION & ASS
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:LONGENECKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:574-536-9867
Mailing Address - Street 1:25508 COUNTY ROAD 126
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46517-9188
Mailing Address - Country:US
Mailing Address - Phone:574-536-9867
Mailing Address - Fax:574-875-7096
Practice Address - Street 1:215 E UNIVERSITY DR
Practice Address - Street 2:SUITE 150
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-4000
Practice Address - Country:US
Practice Address - Phone:574-272-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LONGENECKER VISION & ASSOCIATES, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-18
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001765B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty