| Organization Name: | LOGAN PRIMARY CARE SERVICE CORP. |
| NPI Number: | 1023123346 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | TARA G DEATON (ADMINISTRATOR) |
| Mailing Address: | 502 W St Louis West Frankfort |
| State: | IL US |
| Postal Code: | 62896 |
| Phone Number: | 6189973400 |
| Fax Number: | 6189323797 |
| NPI Enumeration Date: | 08/19/2006 |
| NPI Last Update Date: | 03/16/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QR1300X |
| License Number: | 036099669 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Rural Health |
| Taxonomy Definition: | |