Healthcare Provider Details

I. General information

NPI: 1265802979
Provider Name (Legal Business Name): LOGAN COMMUNITY RESOURCES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 10/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6339 ATLANTIC AVE
KALAMAZOO MI
49009-9572
US

IV. Provider business mailing address

2505 E JEFFERSON BLVD
SOUTH BEND IN
46615-2635
US

V. Phone/Fax

Practice location:
  • Phone: 269-353-9533
  • Fax: 269-353-9566
Mailing address:
  • Phone: 574-289-4831
  • Fax: 574-234-2075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberL893994
License Number StateMI

VIII. Authorized Official

Name: ROBERT MCFARLAND
Title or Position: CONTRACT SPECIALIST
Credential:
Phone: 574-289-4831