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General NPI Number Information
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NPI Number | 1073168399
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Entity Type | Individual
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Provider Name | LOGAN PRESCOTT
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Gender | Male
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Dates
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Enumeration Date | 08/04/2019
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Last Update Date | 08/04/2019
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Provider Practice Location Address
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Address Line | 3545 S NATIONAL AVE
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City | SPRINGFIELD
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State | MO
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Zip | 65807-7310
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Country | US
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Telephone | 417-269-3282
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Fax |
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Provider Business Mailing Address
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Address Line | 5650 E FARM ROAD 132
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City | SPRINGFIELD
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State | MO
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Zip | 65802-9494
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Country | US
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Telephone | 417-880-2865
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081S0010X
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Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 2018029949
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License Number State | MO
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