Basic Information
| Provider Information | |||||||||
| NPI: | 1912632472 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOGAN | ||||||||
| FirstName: | BERT | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | PT, MPT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2350 | ||||||||
| Address2: | |||||||||
| City: | ROCKLIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956778350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668396979 | ||||||||
| FaxNumber: | 9169135646 | ||||||||
| Practice Location | |||||||||
| Address1: | 9620 NE TANASBOURNE DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971247844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668396979 | ||||||||
| FaxNumber: | 9169135646 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2022 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2653 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.