Provider Demographics
NPI:1598501793
Name:SOUTH BEND RESIDENTIAL CARE LLC
Entity type:Organization
Organization Name:SOUTH BEND RESIDENTIAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:BERCHMANS
Authorized Official - Last Name:NITUNGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-312-2620
Mailing Address - Street 1:1602 N BROOKFIELD ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-3008
Mailing Address - Country:US
Mailing Address - Phone:207-312-2620
Mailing Address - Fax:
Practice Address - Street 1:1602 N BROOKFIELD ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-3008
Practice Address - Country:US
Practice Address - Phone:207-312-2620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities