Provider Demographics
NPI:1639643117
Name:KETCHUM, LOGAN MARIE (DC)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:MARIE
Last Name:KETCHUM
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24285 RED ARROW HWY STE A
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-7700
Mailing Address - Country:US
Mailing Address - Phone:269-399-4690
Mailing Address - Fax:
Practice Address - Street 1:24285 RED ARROW HWY STE A
Practice Address - Street 2:
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-7700
Practice Address - Country:US
Practice Address - Phone:269-399-4690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010763111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor