Healthcare Provider Details

I. General information

NPI: 1932128436
Provider Name (Legal Business Name): JEFFERY A LOGAN LAC,LLC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 AUBURN ST STE 103
PORTLAND ME
04103-6004
US

IV. Provider business mailing address

222 AUBURN ST STE 103
PORTLAND ME
04103-6004
US

V. Phone/Fax

Practice location:
  • Phone: 207-780-8880
  • Fax: 207-773-0959
Mailing address:
  • Phone: 207-780-8880
  • Fax: 207-773-0959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC157
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: