Healthcare Provider Details

I. General information

NPI: 1649132101
Provider Name (Legal Business Name): NICHOLAS LOGIE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 TOWN CENTER DR STE 115
WILMINGTON NC
28405-8563
US

IV. Provider business mailing address

4617 IGLEHART CT
WILMINGTON NC
28409-3437
US

V. Phone/Fax

Practice location:
  • Phone: 472-215-8147
  • Fax:
Mailing address:
  • Phone: 910-538-1866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number18970
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: