Provider Demographics
NPI:1740203405
Name:LOGAN, BILL ALAN (DC)
Entity Type:Individual
Prefix:MR
First Name:BILL
Middle Name:ALAN
Last Name:LOGAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17830 BRENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-8153
Mailing Address - Country:US
Mailing Address - Phone:734-246-9961
Mailing Address - Fax:
Practice Address - Street 1:27104 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-3537
Practice Address - Country:US
Practice Address - Phone:586-751-1977
Practice Address - Fax:586-751-1929
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005438111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4510951Medicaid
MI4510951Medicaid