Provider Demographics
NPI: | 1891031191 |
---|---|
Name: | LOGAN PHYSICIAN PRACTICE LLC |
Entity Type: | Organization |
Organization Name: | LOGAN PHYSICIAN PRACTICE LLC |
Other - Org Name: | AUBURN COMMUNITY HEALTH CLINIC |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | VP AND CORPORATE SECRETARY |
Authorized Official - Prefix: | |
Authorized Official - First Name: | KATHY |
Authorized Official - Middle Name: | J |
Authorized Official - Last Name: | TEAGUE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 629-253-5121 |
Mailing Address - Street 1: | 128 SUGAR MAPLE DR |
Mailing Address - Street 2: | |
Mailing Address - City: | AUBURN |
Mailing Address - State: | KY |
Mailing Address - Zip Code: | 42206-5352 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 270-344-5157 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 128 SUGAR MAPLE DR |
Practice Address - Street 2: | |
Practice Address - City: | AUBURN |
Practice Address - State: | KY |
Practice Address - Zip Code: | 42206-5352 |
Practice Address - Country: | US |
Practice Address - Phone: | 270-344-5157 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | LOGAN PHYSICIAN PRACTICE LLC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2012-12-14 |
Last Update Date: | 2023-11-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QR1300X | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |