Healthcare Provider Details

I. General information

NPI: 1902044597
Provider Name (Legal Business Name): LOGAN FAMILY PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2009
Last Update Date: 02/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GALLEGOS
LOGAN NM
88426-7602
US

IV. Provider business mailing address

600 GALLEGOS
LOGAN NM
88426-7602
US

V. Phone/Fax

Practice location:
  • Phone: 575-487-9000
  • Fax: 575-487-9002
Mailing address:
  • Phone: 575-487-9000
  • Fax: 575-487-9002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR14626
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberR14626
License Number StateNM

VIII. Authorized Official

Name: MRS. LAJUANA DELL WILLIS
Title or Position: MEMBER
Credential: CFNP
Phone: 575-487-9000