Provider Demographics
NPI:1093083461
Name:LOGAN COMMUNITY RESOURCES, INC
Entity Type:Organization
Organization Name:LOGAN COMMUNITY RESOURCES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARRON
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-289-4831
Mailing Address - Street 1:2505 E JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-2635
Mailing Address - Country:US
Mailing Address - Phone:574-289-4831
Mailing Address - Fax:574-234-2075
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:574-234-2075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201036530Medicaid