Healthcare Provider Details

I. General information

NPI: 1962367136
Provider Name (Legal Business Name): LOGAN VAN SANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3507 LEE BLVD STE 101
LEHIGH ACRES FL
33971-1325
US

IV. Provider business mailing address

12950 GROVER RD
JACKSONVILLE FL
32226-1940
US

V. Phone/Fax

Practice location:
  • Phone: 239-256-3264
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number44160
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: