MEDICARE: MS. LORI ALICE LOGAN CGC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	170300000X	Genetic Counselor (M.S.)

General Provider Information

NPI Number	:	1225027899
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LORI ALICE LOGAN CGC

Provider Business Mailing Address
First Line	:	604 BORIS AVE
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89015-1526
Country	:	US
Telephone Number	:	702-568-1982
Fax Number	:

Provider Business Practice Location Address
First Line	:	9280 W SUNSET RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-4861
Country	:	US
Telephone Number	:	702-341-6610
Fax Number	:	702-341-6961

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2005
Last Update Date	:	07/08/2007

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