Healthcare Provider Details

I. General information

NPI: 1073680419
Provider Name (Legal Business Name): THE SOUTH BEND CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N EDDY ST
SOUTH BEND IN
46617-2808
US

IV. Provider business mailing address

6301 UNIVERSITY COMMONS STE 230
SOUTH BEND IN
46635-1590
US

V. Phone/Fax

Practice location:
  • Phone: 574-299-2450
  • Fax: 574-299-2415
Mailing address:
  • Phone: 574-251-2115
  • Fax: 574-251-2150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number15D0357414
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. PAUL J MEYER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 574-237-9201