Provider Demographics
NPI:1013424357
Name:NORTH, LOGAN TYLER (DC)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:TYLER
Last Name:NORTH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-2894
Mailing Address - Country:US
Mailing Address - Phone:636-240-2225
Mailing Address - Fax:
Practice Address - Street 1:109 CHURCH ST
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-2894
Practice Address - Country:US
Practice Address - Phone:636-240-2225
Practice Address - Fax:636-281-5377
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5562111N00000X
MO2020035024111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY5562OtherSTATE LICENSE BOARD
MO2020035024OtherSTATE LICENSE BOARD