Provider Demographics
NPI:1508588088
Name:BENEDICT, LOGAN
Entity Type:Individual
Prefix:MR
First Name:LOGAN
Middle Name:
Last Name:BENEDICT
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 1:659 KAYS POINT RD
Mailing Address - Street 2:
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049-4779
Mailing Address - Country:US
Mailing Address - Phone:573-723-0521
Mailing Address - Fax:
Practice Address - Street 1:100 E NORMAL AVE
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-4221
Practice Address - Country:US
Practice Address - Phone:573-723-0521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program