Provider Demographics
NPI:1316094659
Name:LONGENECKER, ROBERT JEFFERY (DC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JEFFERY
Last Name:LONGENECKER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 ESTERS RD APT 114
Mailing Address - Street 2:PO BOX 177128
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-9396
Mailing Address - Country:US
Mailing Address - Phone:972-790-8236
Mailing Address - Fax:972-790-8227
Practice Address - Street 1:1405 ESTERS RD APT 114
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-9396
Practice Address - Country:US
Practice Address - Phone:972-790-8236
Practice Address - Fax:972-790-8227
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4014111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0200XChiropractic ProvidersChiropractorRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX601416Medicare UPIN