MEDICARE: LOGAN ROBERTS

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	132700000X	Dietary Manager

General Provider Information

NPI Number	:	1285565192
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOGAN ROBERTS

Provider Business Mailing Address
First Line	:	1120 2ND LOOP RD
Second Line	:
City	:	FLORENCE
State	:	SC
Zip	:	29505-2834
Country	:	US
Telephone Number	:	843-461-5125
Fax Number	:

Provider Business Practice Location Address
First Line	:	1120 2ND LOOP RD
Second Line	:
City	:	FLORENCE
State	:	SC
Zip	:	29505-2834
Country	:	US
Telephone Number	:	843-461-5125
Fax Number	:

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

Provider Enumeration Date	:	05/28/2026
Last Update Date	:	05/28/2026

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Directions to “ LOGAN ROBERTS ” Practice Location

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