Provider Demographics
NPI:1033378807
Name:LOGAN COMMUNITY RESOURCES
Entity Type:Organization
Organization Name:LOGAN COMMUNITY RESOURCES
Other - Org Name:LOGAN BUILDING BLOCKS
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARSHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-289-4831
Mailing Address - Street 1:PO BOX 1049
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46624-1049
Mailing Address - Country:US
Mailing Address - Phone:574-289-4831
Mailing Address - Fax:
Practice Address - Street 1:2505 E JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-2635
Practice Address - Country:US
Practice Address - Phone:574-289-4831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200713940Medicaid