Healthcare Provider Details

I. General information

NPI: 1538257167
Provider Name (Legal Business Name): THE SOUTH BEND CLINIC LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N EDDY ST
SOUTH BEND IN
46617-2808
US

IV. Provider business mailing address

PO BOX 715223
CINCINNATI OH
45271-5223
US

V. Phone/Fax

Practice location:
  • Phone: 574-246-8816
  • Fax: 574-237-9309
Mailing address:
  • Phone: 574-299-2450
  • Fax: 574-299-2415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. KELLY E. MACKEN-MARBLE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 574-237-9201