Provider Demographics
NPI:1992049894
Name:KANODE, LOGAN ARDEN (PT, DPT, CWC)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:ARDEN
Last Name:KANODE
Suffix:
Gender:M
Credentials:PT, DPT, CWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 N PRINCE ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4850
Mailing Address - Country:US
Mailing Address - Phone:575-935-0360
Mailing Address - Fax:575-935-0361
Practice Address - Street 1:1609 N PRINCE ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4850
Practice Address - Country:US
Practice Address - Phone:505-454-1213
Practice Address - Fax:505-425-2798
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT4234225100000X
NM4234225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist