Provider Demographics
NPI:1376008847
Name:LOGAN, RIDGE
Entity Type:Individual
Prefix:
First Name:RIDGE
Middle Name:
Last Name:LOGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12509 STEPHENSON LEVY RD
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-7971
Mailing Address - Country:US
Mailing Address - Phone:817-991-9784
Mailing Address - Fax:
Practice Address - Street 1:12509 STEPHENSON LEVY RD
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-7971
Practice Address - Country:US
Practice Address - Phone:817-991-9784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX950616163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse