Healthcare Provider Details

I. General information

NPI: 1003746207
Provider Name (Legal Business Name): LOGAN P SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

548 S 700 W
SALT LAKE CITY UT
84104-1086
US

IV. Provider business mailing address

548 S 700 W
SALT LAKE CITY UT
84104-1086
US

V. Phone/Fax

Practice location:
  • Phone: 385-456-9160
  • Fax:
Mailing address:
  • Phone: 385-456-9160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberF24-113089
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: