Provider Demographics
NPI:1114310018
Name:CHAMBERLAIN, LOGAN P (DC, ATC)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:P
Last Name:CHAMBERLAIN
Suffix:
Gender:M
Credentials:DC, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6296 W. BOGGSTOWN RD.
Mailing Address - Street 2:
Mailing Address - City:BOGGSTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1332 W ARCH HAVEN AVE STE C
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2078
Practice Address - Country:US
Practice Address - Phone:812-333-7447
Practice Address - Fax:812-333-7442
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-17
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
IN08003143A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty