Healthcare Provider Details

I. General information

NPI: 1073387114
Provider Name (Legal Business Name): LOGAN E BARGERON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2023
Last Update Date: 10/07/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

873 WESTFIELD ROAD
STATEBORO GA
30458
US

IV. Provider business mailing address

2431 STONEY BLUFF RD
GIRARD GA
30426-3843
US

V. Phone/Fax

Practice location:
  • Phone: 912-764-6297
  • Fax:
Mailing address:
  • Phone: 706-551-4772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: