Provider Demographics
NPI:1871206300
Name:LL PROVIDER INC
Entity type:Organization
Organization Name:LL PROVIDER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:LORNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-861-0127
Mailing Address - Street 1:12668 CHAPMAN AVE UNIT 2107
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-4037
Mailing Address - Country:US
Mailing Address - Phone:949-861-0127
Mailing Address - Fax:
Practice Address - Street 1:12668 CHAPMAN AVE UNIT 2107
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4037
Practice Address - Country:US
Practice Address - Phone:949-861-0127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-29
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care