Healthcare Provider Details

I. General information

NPI: 1578468468
Provider Name (Legal Business Name): LOGAN HUNTER BOOTHE NRP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2026
Last Update Date: 10/10/2026
Certification Date: 10/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 BRENTWOOD RD
EDEN NC
27288-6306
US

IV. Provider business mailing address

907 BRENTWOOD RD
EDEN NC
27288-6306
US

V. Phone/Fax

Practice location:
  • Phone: 336-520-7994
  • Fax:
Mailing address:
  • Phone: 336-520-7994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberP119482
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: