NPIMap

Organization Active NPI

Logan Community Resources, Inc.

  • Intellectual and/or Developmental Disabilities Residential Treatment Facility
  • South Bend, IN
National Provider Identifier
1891917449
Registry record updated Aug 1, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual and/or Developmental Disabilities Residential Treatment FacilityTaxonomy code 320600000X
Legal business name
LOGAN COMMUNITY RESOURCES, INC.
Practice address
2505 E. Jefferson Blvd
South Bend, IN 46615
Phone
(574) 289-4831
Fax
(574) 234-2075
NPI assigned
May 3, 2007
Last updated
Aug 1, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 1, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Clint Bolser
Title
Ceo
Phone
(574) 289-4831

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Developmentally Disabled Services Day Training Agency 251C00000X NU
Intellectual and/or Developmental Disabilities Residential Treatment Facility 320600000X NU Primary
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility 320900000X NU
Community/Behavioral Health Agency 251S00000X NU

Addresses

Primary practice location

2505 E. Jefferson Blvd
South Bend, IN 46615

Mailing address

2505 E. Jefferson Blvd
South Bend, IN 46615
Phone (574) 289-4831

Other identifiers 2

IdentifierTypeStateIssuer
201036530MedicaidIN
100108330MedicaidIN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20161004002087 MI Part B Supplier - Clinic/Group Practice 2961790126 Receives reassigned benefits from 1 practitioner
Practice locations: Benton Harbor, MI

National Provider Directory

National Provider Directory
Tax ID family
Logan Community Resources Inc14 organizations share this tax ID, including this one

Other organizations with this tax ID 13

Organizations that report the same tax identification number in the National Provider Directory.

View all 13

Locations

51960 Gumwood Rd
Granger, IN 46530
Phone (574) 247-4665

Practitioners & affiliated clinicians

Practitioners 25

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 25

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1178150400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1343779200000",
    "number": "1891917449",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2505 E. JEFFERSON BLVD",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "46615",
            "telephone_number": "574-289-4831",
            "fax_number": "574-234-2075"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2505 E. JEFFERSON BLVD",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "46615",
            "telephone_number": "574-289-4831",
            "fax_number": "574-234-2075"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LOGAN COMMUNITY RESOURCES, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-03",
        "last_updated": "2012-08-01",
        "status": "A",
        "authorized_official_last_name": "BOLSER",
        "authorized_official_first_name": "CLINT",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "574-289-4831",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "251C00000X",
            "taxonomy_group": "",
            "desc": "Day Training, Developmentally Disabled Services",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "320600000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "320900000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "201036530",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100108330",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in South Bend, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 1, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.