MEDICARE: LOGAN JUSTIN APPLEDOORN PT

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	225100000X	Physical Therapist	301768	CA

General Provider Information

NPI Number	:	1184370959
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOGAN JUSTIN APPLEDOORN PT

Provider Business Mailing Address
First Line	:	1252 BROADWAY STE B
Second Line	:
City	:	PLACERVILLE
State	:	CA
Zip	:	95667-5827
Country	:	US
Telephone Number	:	530-622-9410
Fax Number	:

Provider Business Practice Location Address
First Line	:	12150 INDUSTRY BLVD STE 42
Second Line	:
City	:	JACKSON
State	:	CA
Zip	:	95642-9375
Country	:	US
Telephone Number	:	209-223-9410
Fax Number	:

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

Provider Enumeration Date	:	03/01/2022
Last Update Date	:	03/01/2022

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Directions to “ LOGAN JUSTIN APPLEDOORN PT” Practice Location

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