Provider Demographics
NPI:1467406827
Name:LOGAN, KENNETH OWEN (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:OWEN
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 HERITAGE CIR
Mailing Address - Street 2:APT 406
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-5685
Mailing Address - Country:US
Mailing Address - Phone:678-493-3502
Mailing Address - Fax:
Practice Address - Street 1:24 WALESKA ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2739
Practice Address - Country:US
Practice Address - Phone:770-345-7896
Practice Address - Fax:770-345-4096
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICHIR001489111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor