Healthcare Provider Details

I. General information

NPI: 1831854884
Provider Name (Legal Business Name): LOGAN BURNS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2021
Last Update Date: 11/04/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12413 JUDSON RD STE 200
LIVE OAK TX
78233-3215
US

IV. Provider business mailing address

12413 JUDSON RD STE 200
LIVE OAK TX
78233-3215
US

V. Phone/Fax

Practice location:
  • Phone: 210-653-1722
  • Fax: 210-653-1742
Mailing address:
  • Phone: 210-653-1722
  • Fax: 210-653-1742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number80952
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: