Healthcare Provider Details

I. General information

NPI: 1841435997
Provider Name (Legal Business Name): COQUICE LOGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2008
Last Update Date: 12/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6312 SNOW RIDGE CT
ARLINGTON TX
76018-3160
US

IV. Provider business mailing address

6312 SNOW RIDGE CT
ARLINGTON TX
76018-3160
US

V. Phone/Fax

Practice location:
  • Phone: 817-468-3847
  • Fax: 817-468-5977
Mailing address:
  • Phone: 817-468-3847
  • Fax: 817-468-5977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: