=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598055741
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN A. LOGAN COLLEGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2011
-----------------------------------------------------
Last Update Date | 04/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 LOGAN COLLEGE DR
-----------------------------------------------------
City | CARTERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62918-2500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-985-2828
-----------------------------------------------------
Fax | 618-985-4654
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 LOGAN COLLEGE DR
-----------------------------------------------------
City | CARTERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62918-2500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-985-2828
-----------------------------------------------------
Fax | 618-985-4654
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DEPARTMENT CHAIR FOR ALLIED HEALTH
-----------------------------------------------------
Name | MRS. PAM RUTH KARNS
-----------------------------------------------------
Credential | RDH, MS
-----------------------------------------------------
Telephone | 618-985-2828
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019.018274
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------