MEDICARE: COQUICE 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	332BC3200X	Customized Equipment (DME)

General Provider Information

NPI Number	:	1841435997
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COQUICE LOGAN

Provider Business Mailing Address
First Line	:	6312 SNOW RIDGE CT
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76018-3160
Country	:	US
Telephone Number	:	817-468-3847
Fax Number	:	817-468-5977

Provider Business Practice Location Address
First Line	:	6312 SNOW RIDGE CT
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76018-3160
Country	:	US
Telephone Number	:	817-468-3847
Fax Number	:	817-468-5977

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

Provider Enumeration Date	:	12/03/2008
Last Update Date	:	12/03/2008

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Directions to “ COQUICE LOGAN ” Practice Location

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