Provider Demographics
NPI:1386862480
Name:KENNETH O LOGAN, D.C.,P.C.
Entity Type:Organization
Organization Name:KENNETH O LOGAN, D.C.,P.C.
Other - Org Name:LOGAN CHIROPRACTIC LIFE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:OWEN
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-428-3671
Mailing Address - Street 1:2543 BELLS FERRY RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-5179
Mailing Address - Country:US
Mailing Address - Phone:770-428-3671
Mailing Address - Fax:770-428-2143
Practice Address - Street 1:2543 BELLS FERRY RD
Practice Address - Street 2:SUITE 500
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-5179
Practice Address - Country:US
Practice Address - Phone:770-428-3671
Practice Address - Fax:770-428-2143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001489111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA377562280AMedicare ID - Type Unspecified