Healthcare Provider Details

I. General information

NPI: 1699102046
Provider Name (Legal Business Name): BEACON HEALTH VENTURES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2013
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3355 DOUGLAS RD
SOUTH BEND IN
46635
US

IV. Provider business mailing address

3355 DOUGLAS RD SUITE 400
SOUTH BEND IN
46635-1781
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-2273
  • Fax:
Mailing address:
  • Phone: 574-647-2273
  • Fax: 574-647-8764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number60004143A
License Number StateIN

VIII. Authorized Official

Name: MR. GREG CONRAD
Title or Position: VICE PRESIDENT
Credential:
Phone: 574-647-8777