1902044597 NPI number — LOGAN FAMILY PRACTICE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902044597 NPI number — LOGAN FAMILY PRACTICE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOGAN FAMILY PRACTICE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1902044597
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 GALLEGOS
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOGAN
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88426-7602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-487-9000
Provider Business Mailing Address Fax Number:
575-487-9002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 GALLEGOS
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88426-7602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-487-9000
Provider Business Practice Location Address Fax Number:
575-487-9002
Provider Enumeration Date:
02/04/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIS
Authorized Official First Name:
LAJUANA
Authorized Official Middle Name:
DELL
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
575-487-9000

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R14626 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X , with the licence number: R14626 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 28184564 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com