Healthcare Provider Details

I. General information

NPI: 1083634133
Provider Name (Legal Business Name): BECKY M. LOGAN SURGICAL TECH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 AUDUBON AVE STE S-4
THIBODAUX LA
70301-4957
US

IV. Provider business mailing address

203 ORMOND VILLAGE DR
DESTREHAN LA
70047-3717
US

V. Phone/Fax

Practice location:
  • Phone: 985-447-7246
  • Fax:
Mailing address:
  • Phone: 985-764-6952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: