Basic Information
| Provider Information | |||||||||
| NPI: | 1689982969 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONGSWORTH | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | ERNEST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2809 CHUCKWAGON RD | ||||||||
| Address2: | |||||||||
| City: | PALMDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935505993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6615264506 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1609 E PALMDALE BLVD | ||||||||
| Address2: | SUITE G | ||||||||
| City: | PALMDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935504881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6619471595 | ||||||||
| FaxNumber: | 6612720415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2010 | ||||||||
| LastUpdateDate: | 09/20/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.