Provider Demographics
NPI:1265068233
Name:DIANE LOGAN LLC
Entity type:Organization
Organization Name:DIANE LOGAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:E
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, CSAC
Authorized Official - Phone:808-437-7447
Mailing Address - Street 1:PO BOX 5488
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96745-5488
Mailing Address - Country:US
Mailing Address - Phone:808-437-7447
Mailing Address - Fax:808-374-9046
Practice Address - Street 1:75-127 LUNAPULE RD STE 15B
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-2119
Practice Address - Country:US
Practice Address - Phone:808-437-7447
Practice Address - Fax:808-374-9046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-20
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder