Healthcare Provider Details

I. General information

NPI: 1578619078
Provider Name (Legal Business Name): BEACON HEALTH VENTURES MICHIGAN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 02/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69045 M-62 SUITE A-1
EDWARDSBURG MI
49112
US

IV. Provider business mailing address

3355 DOUGLAS ROAD
SOUTH BEND IN
46635
US

V. Phone/Fax

Practice location:
  • Phone: 269-663-2201
  • Fax: 269-663-2209
Mailing address:
  • Phone: 574-647-8731
  • Fax: 574-647-8768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SANDRA L SMIGIELSKI
Title or Position: MANAGER
Credential:
Phone: 574-647-8731