Healthcare Provider Details

I. General information

NPI: 1104738012
Provider Name (Legal Business Name): LOGAN CHRISTOFF JACKSON GOVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 UNIVERSITY CITY BLVD
CHARLOTTE NC
28223-0001
US

IV. Provider business mailing address

7600 KC FARM RD
CARY NC
27519-6090
US

V. Phone/Fax

Practice location:
  • Phone: 704-687-8622
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: