Provider Demographics
NPI:1598055741
Name:JOHN A. LOGAN COLLEGE
Entity Type:Organization
Organization Name:JOHN A. LOGAN COLLEGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT CHAIR FOR ALLIED HEALTH
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAM
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:KARNS
Authorized Official - Suffix:
Authorized Official - Credentials:RDH, MS
Authorized Official - Phone:618-985-2828
Mailing Address - Street 1:700 LOGAN COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-2500
Mailing Address - Country:US
Mailing Address - Phone:618-985-2828
Mailing Address - Fax:618-985-4654
Practice Address - Street 1:700 LOGAN COLLEGE DR
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-2500
Practice Address - Country:US
Practice Address - Phone:618-985-2828
Practice Address - Fax:618-985-4654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-08
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.018274122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty