Provider Demographics
NPI:1528653722
Name:VANCE, LOGAN
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:VANCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:586 MONDAY ADDITION
Mailing Address - Street 2:
Mailing Address - City:WEST HAMLIN
Mailing Address - State:WV
Mailing Address - Zip Code:25571-9713
Mailing Address - Country:US
Mailing Address - Phone:304-710-6129
Mailing Address - Fax:
Practice Address - Street 1:586 MONDAY ADDITION
Practice Address - Street 2:
Practice Address - City:WEST HAMLIN
Practice Address - State:WV
Practice Address - Zip Code:25571-9713
Practice Address - Country:US
Practice Address - Phone:304-710-6129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker