Provider Demographics
NPI:1114940889
Name:LOGAN, ALBERTINA DARICE (DC)
Entity Type:Individual
Prefix:MS
First Name:ALBERTINA
Middle Name:DARICE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1S132 SUMMIT AVE
Mailing Address - Street 2:307
Mailing Address - City:OAKBROOK TERRACE
Mailing Address - State:IL
Mailing Address - Zip Code:60181-3955
Mailing Address - Country:US
Mailing Address - Phone:630-705-1475
Mailing Address - Fax:630-705-1556
Practice Address - Street 1:1S132 SUMMIT AVE
Practice Address - Street 2:301
Practice Address - City:OAKBROOK TERRACE
Practice Address - State:IL
Practice Address - Zip Code:60181-3955
Practice Address - Country:US
Practice Address - Phone:630-705-1475
Practice Address - Fax:630-705-1556
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-010645111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1588970651Medicare PIN