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General NPI Number Information
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NPI Number | 1346865110
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Entity Type | Individual
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Provider Name | LOGAN NICHOLAS TAYLOR DPT
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Gender | Male
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Dates
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Enumeration Date | 06/08/2020
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Last Update Date | 06/08/2020
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Provider Practice Location Address
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Address Line | 102 S FORREST AVE
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City | LIBERTY
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State | MO
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Zip | 64068-1908
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Country | US
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Telephone | 816-429-5199
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Fax | 816-429-7129
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Provider Business Mailing Address
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Address Line | 102 S FORREST AVE
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City | LIBERTY
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State | MO
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Zip | 64068-1908
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Country | US
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Telephone | 816-429-5199
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Fax | 816-429-7129
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 2020015509
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License Number State | MO
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