Healthcare Provider Details

I. General information

NPI: 1073168399
Provider Name (Legal Business Name): LOGAN PRESCOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2019
Last Update Date: 08/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3545 S NATIONAL AVE
SPRINGFIELD MO
65807-7310
US

IV. Provider business mailing address

5650 E FARM ROAD 132
SPRINGFIELD MO
65802-9494
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-3282
  • Fax:
Mailing address:
  • Phone: 417-880-2865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number2018029949
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: