Provider Demographics
NPI:1235298019
Name:LOGAN, ROBERT (DC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:LOGAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 AUTO CENTER CT
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-1573
Mailing Address - Country:US
Mailing Address - Phone:209-527-5433
Mailing Address - Fax:209-527-3128
Practice Address - Street 1:200 AUTO CENTER CT
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-1573
Practice Address - Country:US
Practice Address - Phone:209-527-5433
Practice Address - Fax:209-527-3128
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20679111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA770393158OtherTAX ID