Healthcare Provider Details

I. General information

NPI: 1366156713
Provider Name (Legal Business Name): LOGAN JAMES BAHMER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2023
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 8TH ST
FARMINGTON MN
55024-1403
US

IV. Provider business mailing address

509 8TH ST
FARMINGTON MN
55024-1403
US

V. Phone/Fax

Practice location:
  • Phone: 760-672-7786
  • Fax:
Mailing address:
  • Phone: 760-672-7786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code374K00000X
TaxonomyReligious Nonmedical Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: