Healthcare Provider Details

I. General information

NPI: 1174007686
Provider Name (Legal Business Name): LOGAN EATON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N MAIN ST SUITE 200
SANTA ANA CA
92701
US

IV. Provider business mailing address

1200 N MAIN ST STE 200
SANTA ANA CA
92701-3640
US

V. Phone/Fax

Practice location:
  • Phone: 714-480-6767
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: