Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | 1465 | MA |
NPI | 1548323140 |
---|---|
Provider Name | Mark Logan |
First Address | Braintree, MA 02184-6854 |
Second Address | Braintree, MA 02184-2404 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/12/2006 |
Last Update Date | 13/01/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T-91233 | (02) | MA |