Healthcare Provider Details

I. General information

NPI: 1598376485
Provider Name (Legal Business Name): THE SOUTH BEND CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 UNIVERSITY COMMONS
SOUTH BEND IN
46635-1571
US

IV. Provider business mailing address

211 N EDDY ST
SOUTH BEND IN
46617-3096
US

V. Phone/Fax

Practice location:
  • Phone: 574-247-4667
  • Fax: 574-271-4458
Mailing address:
  • Phone: 574-239-1567
  • Fax: 574-239-1458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER LYNN HILER
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 574-239-1567