MEDICARE: CONOR LOGAN

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	171100000X	Acupuncturist	16258	CA

General Provider Information

NPI Number	:	1447654603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONOR LOGAN

Provider Business Mailing Address
First Line	:	4834 STERN AVE
Second Line	:
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91423-1924
Country	:	US
Telephone Number	:	323-213-9220
Fax Number	:

Provider Business Practice Location Address
First Line	:	3380 BEAR CREEK DR
Second Line	:
City	:	NEWBURY PARK
State	:	CA
Zip	:	91320-5008
Country	:	US
Telephone Number	:	323-213-9220
Fax Number	:

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

Provider Enumeration Date	:	10/17/2014
Last Update Date	:	10/02/2021

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Directions to “ CONOR LOGAN ” Practice Location

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