Healthcare Provider Details

I. General information

NPI: 1891917449
Provider Name (Legal Business Name): LOGAN COMMUNITY RESOURCES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 08/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 E. JEFFERSON BLVD
SOUTH BEND IN
46615
US

IV. Provider business mailing address

2505 E. JEFFERSON BLVD
SOUTH BEND IN
46615
US

V. Phone/Fax

Practice location:
  • Phone: 574-289-4831
  • Fax: 574-234-2075
Mailing address:
  • Phone: 574-289-4831
  • Fax: 574-234-2075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. CLINT BOLSER
Title or Position: CEO
Credential:
Phone: 574-289-4831