Provider Demographics
NPI:1750814695
Name:MIKKELSON, LOGAN MICHAEL (DC)
Entity type:Individual
Prefix:DR
First Name:LOGAN
Middle Name:MICHAEL
Last Name:MIKKELSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 S RESERVE ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-4755
Mailing Address - Country:US
Mailing Address - Phone:406-549-2006
Mailing Address - Fax:406-549-6574
Practice Address - Street 1:1519 S RESERVE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-4755
Practice Address - Country:US
Practice Address - Phone:406-549-2006
Practice Address - Fax:406-549-6574
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-07
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7524111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor