Healthcare Provider Details

I. General information

NPI: 1548594435
Provider Name (Legal Business Name): HALEY DURRETTE LOGAN D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HALEY DURRETTE LAUCKEM D.C.

II. Dates (important events)

Enumeration Date: 09/24/2009
Last Update Date: 10/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 ABERDEEN RD
HAMPTON VA
23661
US

IV. Provider business mailing address

704 THIMBLE SHOALS STE. 200
NEWPORT NEWS VA
23602
US

V. Phone/Fax

Practice location:
  • Phone: 757-825-1100
  • Fax:
Mailing address:
  • Phone: 757-825-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104556746
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberL1605238
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: