Healthcare Provider Details

I. General information

NPI: 1265028971
Provider Name (Legal Business Name): BEACON HEALTH VENTURES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3355 DOUGLAS RD
SOUTH BEND IN
46635-1779
US

IV. Provider business mailing address

3355 DOUGLAS RD
SOUTH BEND IN
46635-1779
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-8675
  • Fax: 574-647-8764
Mailing address:
  • Phone: 574-647-8675
  • Fax: 574-647-8764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
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

VIII. Authorized Official

Name: TRUDY KAY WAIT
Title or Position: PHARMACY MANAGER
Credential:
Phone: 574-647-8674