MEDICARE: ROBERT JAMES LOGAN

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1427277185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT JAMES LOGAN

Provider Business Mailing Address
First Line	:	4426 HUDDART AVE
Second Line	:
City	:	EL MONTE
State	:	CA
Zip	:	91731-1424
Country	:	US
Telephone Number	:	626-279-9542
Fax Number	:	323-664-7342

Provider Business Practice Location Address
First Line	:	4445 BURNS AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-2702
Country	:	US
Telephone Number	:	323-664-8969
Fax Number	:	323-664-1786

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

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	07/08/2007

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