Provider Demographics
NPI:1518502822
Name:LOGAN, CHARLES AUGUSTUS JR
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:AUGUSTUS
Last Name:LOGAN
Suffix:JR
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 1:625 PINEY FOREST RD STE 307B
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-2869
Mailing Address - Country:US
Mailing Address - Phone:434-797-1292
Mailing Address - Fax:
Practice Address - Street 1:625 PINEY FOREST RD STE 307B
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-2869
Practice Address - Country:US
Practice Address - Phone:434-797-1292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker