Provider Demographics
NPI:1891917449
Name:LOGAN COMMUNITY RESOURCES, INC.
Entity Type:Organization
Organization Name:LOGAN COMMUNITY RESOURCES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLSER
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
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
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:2007-05-03
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100108330Medicaid
IN201036530Medicaid