Provider Demographics
NPI:1780012757
Name:NORTHWEST SPINE & WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:NORTHWEST SPINE & WELLNESS CENTER, LLC
Other - Org Name:LOGAN CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:541-776-4554
Mailing Address - Street 1:835 BENNETT AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6715
Mailing Address - Country:US
Mailing Address - Phone:541-776-4554
Mailing Address - Fax:
Practice Address - Street 1:835 BENNETT AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6715
Practice Address - Country:US
Practice Address - Phone:541-776-4554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3440111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty