Provider Demographics
NPI:1053675363
Name:BEACON HEALTH VENTURES, INC.
Entity Type:Organization
Organization Name:BEACON HEALTH VENTURES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMIGIELSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-647-8731
Mailing Address - Street 1:3355 DOUGLAS RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1781
Mailing Address - Country:US
Mailing Address - Phone:574-647-8731
Mailing Address - Fax:574-647-8768
Practice Address - Street 1:5155 VERDANT DRIVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-5411
Practice Address - Country:US
Practice Address - Phone:574-294-6181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-02
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN15-005298-1251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN157095Medicare Oscar/Certification