Healthcare Provider Details

I. General information

NPI: 1457562738
Provider Name (Legal Business Name): PROFESSIONAL ELECTROPHYSIOLOGICAL MEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29301 N. DIXIE RANCH RD.
LACOMBE LA
70445-2290
US

IV. Provider business mailing address

29301 N. DIXIE RANCH RD.
LACOMBE LA
70445-2290
US

V. Phone/Fax

Practice location:
  • Phone: 985-871-4114
  • Fax: 985-871-4130
Mailing address:
  • Phone: 985-871-4114
  • Fax: 985-871-4130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN LOGAN
Title or Position: OWNER
Credential: MD
Phone: 985-871-4114