Healthcare Provider Details

I. General information

NPI: 1306236526
Provider Name (Legal Business Name): LOGIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 INDIANA ST STE 320
GOLDEN CO
80401-5033
US

IV. Provider business mailing address

PO BOX 18818
GOLDEN CO
80402-6047
US

V. Phone/Fax

Practice location:
  • Phone: 720-606-2884
  • Fax: 720-606-2884
Mailing address:
  • Phone: 720-606-2884
  • Fax: 720-606-2884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number20156000150
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateCO

VIII. Authorized Official

Name: JON TIEDE
Title or Position: DIRECTOR OF FINANCIAL SERVICES
Credential:
Phone: 720-600-2304