Provider Demographics
NPI:1952482432
Name:LOGAN, KENTON R (PT)
Entity Type:Individual
Prefix:
First Name:KENTON
Middle Name:R
Last Name:LOGAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5435 HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:MARKSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71351
Mailing Address - Country:US
Mailing Address - Phone:318-253-8846
Mailing Address - Fax:318-253-8875
Practice Address - Street 1:5435 HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:MARKSVILLE
Practice Address - State:LA
Practice Address - Zip Code:71351
Practice Address - Country:US
Practice Address - Phone:318-253-8846
Practice Address - Fax:318-253-8875
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA03521174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist