Provider Demographics
NPI:1447082789
Name:LATVIS, LOGAN HOWARD DANIEL (PTA)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:HOWARD DANIEL
Last Name:LATVIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:MASS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49948-5107
Mailing Address - Country:US
Mailing Address - Phone:906-390-2185
Mailing Address - Fax:
Practice Address - Street 1:CORNER OF RTE 12 AND, RTE 7
Practice Address - Street 2:
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4159-19225200000X
MI5502008461225200000X
IN06006862A225200000X
AZCP033283A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant