Healthcare Provider Details

I. General information

NPI: 1477093789
Provider Name (Legal Business Name): LEWIS E LOGAN II MDIV, THM, DMIN, CPE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 03/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 N. PRAIRIE AVE. SUITE 417
INGLEWOOD CA
90301
US

IV. Provider business mailing address

10747 MAGNOLIA BLVD 418
NORTH HOLLYWOOD CA
91601-4093
US

V. Phone/Fax

Practice location:
  • Phone: 310-680-1810
  • Fax:
Mailing address:
  • Phone: 310-936-7703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: