Organization
LOGAN COMMUNITY RESOURCES, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. CLINT BOLSER (CEO)
(574) 289-4831
Entity
Organization
Contact information
Practice address
2505 E. JEFFERSON BLVD, SOUTH BEND, IN 46615
(574) 289-4831
(574) 234-2075
Mailing address
2505 E. JEFFERSON BLVD, SOUTH BEND, IN 46615
(574) 289-4831
(574) 234-2075
Taxonomy
Speciality
Code
Description
License number
State
251C00000X
Developmentally Disabled Services Day Training Agency
—
—
251S00000X
Community/Behavioral Health Agency
—
—
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
Primary
—
—
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100108330
—
IN
05
—
201036530
—
IN
Enumeration date
05/03/2007
Last updated
08/01/2012
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