Provider Demographics
NPI:1245870799
Name:LOGAN WELLNESS ADVANCED NURSING PRACTICE CORP
Entity type:Organization
Organization Name:LOGAN WELLNESS ADVANCED NURSING PRACTICE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:310-751-1080
Mailing Address - Street 1:538 N DETROIT ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-1949
Mailing Address - Country:US
Mailing Address - Phone:310-751-1080
Mailing Address - Fax:844-941-1989
Practice Address - Street 1:538 N DETROIT ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-1949
Practice Address - Country:US
Practice Address - Phone:310-751-1080
Practice Address - Fax:844-941-1989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-13
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty