Provider Demographics
NPI:1841310653
Name:LOGAN COUNTY BOARD OF MRDD
Entity type:Organization
Organization Name:LOGAN COUNTY BOARD OF MRDD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:F
Authorized Official - Last Name:MANCUSO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:937-292-3009
Mailing Address - Street 1:1851 STATE ROUTE 47 W
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-9328
Mailing Address - Country:US
Mailing Address - Phone:937-592-0015
Mailing Address - Fax:937-592-5615
Practice Address - Street 1:1851 STATE ROUTE 47 W
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-9328
Practice Address - Country:US
Practice Address - Phone:937-592-0015
Practice Address - Fax:937-592-5615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4600015251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0776165Medicaid