| Mount Logan Clinic Llc | |
|
246 E 1260 N Logan UT 84341-7501 | |
| (435) 750-6300 | |
| (435) 753-8995 |
| Full Name | Mount Logan Clinic Llc |
|---|---|
| Speciality | Counselor |
| Location | 246 E 1260 N, Logan, Utah |
| Authorized Official Name and Position | Kyle Hancock (OWNER/PROVIDER) |
| Authorized Official Contact | 4357506300 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Mount Logan Clinic Llc 246 E 1260 N Logan UT 84341-7501 Ph: (435) 750-6300 | Mount Logan Clinic Llc 246 E 1260 N Logan UT 84341-7501 Ph: (435) 750-6300 |
| NPI Number | 1275152910 |
|---|---|
| Provider Enumeration Date | 04/13/2020 |
| Last Update Date | 07/29/2021 |
| Certification Date | 07/29/2021 |
| Medicare PECOS PAC ID | 6002219557 |
|---|---|
| Medicare Enrollment ID | O20210722000079 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1275152910 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Primary |
| Provider Name | Kyle Max Hancock |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1164748729 PECOS PAC ID: 0042490799 Enrollment ID: I20110211000885 |
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