Provider Demographics
NPI:1881432789
Name:DARKHOLME, LOGAN GRAY
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:GRAY
Last Name:DARKHOLME
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:AARON
Other - Middle Name:MICHAEL
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:368 BROADWAY
Mailing Address - Street 2:STE 201
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-5160
Mailing Address - Country:US
Mailing Address - Phone:845-768-0232
Mailing Address - Fax:
Practice Address - Street 1:368 BROADWAY
Practice Address - Street 2:STE 201
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-5160
Practice Address - Country:US
Practice Address - Phone:845-768-0232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist