MEDICARE: LOGAN ASH

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	2255A2300X	Athletic Trainer
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1417403841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOGAN ASH

Provider Business Mailing Address
First Line	:	111 LAKE HOLLINGSWORTH DR
Second Line	:	BOX #4036
City	:	LAKELAND
State	:	FL
Zip	:	33801-5607
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 LAKE HOLLINGSWORTH DR
Second Line	:	BOX #4036
City	:	LAKELAND
State	:	FL
Zip	:	33801-5607
Country	:	US
Telephone Number	:	863-680-4267
Fax Number	:

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

Provider Enumeration Date	:	08/26/2016
Last Update Date	:	08/26/2016

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