Provider Demographics
NPI:1568692127
Name:FULL POTENTIAL LIFE LLC
Entity Type:Organization
Organization Name:FULL POTENTIAL LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LOGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRADDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-321-6171
Mailing Address - Street 1:1530 N GREGSON ST
Mailing Address - Street 2:SUITE 3-D
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-1155
Mailing Address - Country:US
Mailing Address - Phone:919-321-6171
Mailing Address - Fax:888-805-6175
Practice Address - Street 1:1530 N GREGSON ST
Practice Address - Street 2:SUITE 3-D
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-1155
Practice Address - Country:US
Practice Address - Phone:919-321-6171
Practice Address - Fax:888-805-6175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-16
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health