Provider Demographics
NPI:1477811750
Name:LOGAN C MARTIN PC
Entity Type:Organization
Organization Name:LOGAN C MARTIN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LOGAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-292-4873
Mailing Address - Street 1:1911 N QUAIL RUN BLVD
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-6018
Mailing Address - Country:US
Mailing Address - Phone:208-292-4873
Mailing Address - Fax:208-292-4875
Practice Address - Street 1:1019 W LACROSSE AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2418
Practice Address - Country:US
Practice Address - Phone:208-292-4873
Practice Address - Fax:208-292-4875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1192111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1678934OtherPTAN