Provider Demographics
NPI:1750706057
Name:LOGAN FAMILY CARE CENTER LLC
Entity type:Organization
Organization Name:LOGAN FAMILY CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:304-687-2669
Mailing Address - Street 1:557 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-3809
Mailing Address - Country:US
Mailing Address - Phone:304-752-3435
Mailing Address - Fax:
Practice Address - Street 1:557 MAIN ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3809
Practice Address - Country:US
Practice Address - Phone:304-752-3435
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-23
Last Update Date:2014-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty