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General NPI Number Information
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NPI Number | 1457819807
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Entity Type | Individual
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Provider Name | LOGAN HATLEY LAT, ATC, CPT
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Gender | Male
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Dates
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Enumeration Date | 03/05/2019
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Last Update Date | 08/25/2021
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Provider Practice Location Address
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Address Line | 3 GRIER AVE
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City | CHARLESTON
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State | SC
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Zip | 29409-1004
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Country | US
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Telephone | 843-953-6867
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Fax |
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Provider Business Mailing Address
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Address Line | 18525 ROLLINGDALE LN
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City | DAVIDSON
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State | NC
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Zip | 28036-7862
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Country | US
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Telephone | 704-776-3781
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT03092
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License Number State | SC
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