MEDICARE: MR. RICHARD LANE LOGAN RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	164008466	IL

General Provider Information

NPI Number	:	1063189132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICHARD LANE LOGAN RD

Provider Business Mailing Address
First Line	:	2800 N MILWAUKEE AVE APT 504
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-7984
Country	:	US
Telephone Number	:	317-364-2202
Fax Number	:

Provider Business Practice Location Address
First Line	:	2800 N MILWAUKEE AVE APT 504
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-7984
Country	:	US
Telephone Number	:	317-364-2202
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2021
Last Update Date	:	05/28/2026

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