Healthcare Provider Details

I. General information

NPI: 1063892438
Provider Name (Legal Business Name): LOGAN JON SULLIVAN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2015
Last Update Date: 06/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10115 E BELL RD ST. 101 B
SCOTTSDALE AZ
85260-2189
US

IV. Provider business mailing address

PO BOX 18607
FOUNTAIN HILLS AZ
85269-8607
US

V. Phone/Fax

Practice location:
  • Phone: 480-419-3500
  • Fax:
Mailing address:
  • Phone: 480-419-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11583
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: