Provider Demographics
NPI:1558629303
Name:LOGSDON, CONNOR (LMT)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:LOGSDON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 HOOKELE ST
Mailing Address - Street 2:STE 101
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96732-3515
Mailing Address - Country:US
Mailing Address - Phone:808-270-1893
Mailing Address - Fax:808-270-1892
Practice Address - Street 1:77 HOOKELE ST
Practice Address - Street 2:STE 101
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-3515
Practice Address - Country:US
Practice Address - Phone:808-270-1893
Practice Address - Fax:808-270-1892
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-12230225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist