Provider Demographics
NPI:1679337760
Name:DAVIS, LOGAN
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:DAVIS
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 1:2321 TROOST AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-2834
Mailing Address - Country:US
Mailing Address - Phone:402-957-7891
Mailing Address - Fax:402-939-0704
Practice Address - Street 1:2321 TROOST AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-2834
Practice Address - Country:US
Practice Address - Phone:402-957-7891
Practice Address - Fax:402-939-0704
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician