MEDICARE: THE SOUTH BEND CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1538832910
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE SOUTH BEND CLINIC LLC

Provider Business Mailing Address
First Line	:	6301 UNIVERSITY COMMONS STE 230
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46635-1590
Country	:	US
Telephone Number	:	574-239-1567
Fax Number	:	574-239-1458

Provider Business Practice Location Address
First Line	:	2102 E INWOOD RD
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46614-2443
Country	:	US
Telephone Number	:	574-299-2400
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	JENNIFER LYNN HILER
Credential	:
Telephone Number	:	574-239-1567

Provider Enumeration Date	:	07/30/2021
Last Update Date	:	03/22/2022

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