1306401864 NPI number — LOGAN LEE COOK COUNSELOR TECHNICIAN

Table of content: LOGAN LEE COOK COUNSELOR TECHNICIAN (NPI 1306401864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306401864 NPI number — LOGAN LEE COOK COUNSELOR TECHNICIAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOK
Provider First Name:
LOGAN
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
COUNSELOR TECHNICIAN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306401864
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3600 SAN JERONIMO DR STE 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99508-2870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-793-3200
Provider Business Mailing Address Fax Number:
907-793-3250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2953 E FAIRVIEW LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASILLA
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-306-0041
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/09/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 175T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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