Healthcare Provider Details

I. General information

NPI: 1477816080
Provider Name (Legal Business Name): BEACON HEALTH VENTURES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 02/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5155 VERDANT ST
ELKHART IN
46516-9315
US

IV. Provider business mailing address

3355 DOUGLAS RD SUITE 100
SOUTH BEND IN
46635-1781
US

V. Phone/Fax

Practice location:
  • Phone: 574-524-7582
  • Fax: 574-524-7597
Mailing address:
  • Phone: 574-647-8731
  • Fax: 574-647-8768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: GREGORY CONRAD
Title or Position: PRESIDENT
Credential:
Phone: 574-647-8777