MEDICARE: MR. LOGAN TEAL NRP

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	146L00000X	Paramedic	P033707	GA

General Provider Information

NPI Number	:	1700777620
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LOGAN TEAL NRP

Provider Business Mailing Address
First Line	:	619 HERRELL RD
Second Line	:
City	:	VILLA RICA
State	:	GA
Zip	:	30180-4544
Country	:	US
Telephone Number	:	770-527-3729
Fax Number	:

Provider Business Practice Location Address
First Line	:	619 HERRELL RD
Second Line	:
City	:	VILLA RICA
State	:	GA
Zip	:	30180-4544
Country	:	US
Telephone Number	:	770-527-3729
Fax Number	:

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

Provider Enumeration Date	:	07/10/2025
Last Update Date	:	07/10/2025

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Directions to “ MR. LOGAN TEAL NRP” Practice Location

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