MEDICARE: LOGAN FAMILY PRACTICE LLC

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	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1699447169
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOGAN FAMILY PRACTICE LLC

Provider Business Mailing Address
First Line	:	680 S 4TH ST
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40202-2407
Country	:	US
Telephone Number	:	502-596-6063
Fax Number	:

Provider Business Practice Location Address
First Line	:	1719 NASHVILLE ST STE C
Second Line	:
City	:	RUSSELLVILLE
State	:	KY
Zip	:	42276-7804
Country	:	US
Telephone Number	:	270-726-7664
Fax Number	:

Authorized Official
Title or Position	:	AO
Name	:	JOHNETTA TRAYLOR
Credential	:
Telephone Number	:	502-596-6063

Provider Enumeration Date	:	10/01/2021
Last Update Date	:	06/26/2025

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Directions to “LOGAN FAMILY PRACTICE LLC ” Practice Location

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