Provider Demographics
NPI:1821358714
Name:LYNN-LOGUE, CHRISTOPHER RIVERA
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:RIVERA
Last Name:LYNN-LOGUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1296 BAY ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3123
Mailing Address - Country:US
Mailing Address - Phone:917-365-1906
Mailing Address - Fax:
Practice Address - Street 1:2233 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-3045
Practice Address - Country:US
Practice Address - Phone:718-859-9760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program