Provider Demographics
NPI:1629624366
Name:DEROIN, LOGAN (DPT)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:DEROIN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 N LOCUST GROVE RD STE 170
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9379
Mailing Address - Country:US
Mailing Address - Phone:208-917-2660
Mailing Address - Fax:
Practice Address - Street 1:535 N LOCUST GROVE RD STE 170
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9379
Practice Address - Country:US
Practice Address - Phone:208-917-2660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist