Provider Demographics
NPI:1578619078
Name:BEACON HEALTH VENTURES MICHIGAN, INC.
Entity Type:Organization
Organization Name:BEACON HEALTH VENTURES MICHIGAN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMIGIELSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-647-8731
Mailing Address - Street 1:3355 DOUGLAS ROAD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635
Mailing Address - Country:US
Mailing Address - Phone:574-647-8731
Mailing Address - Fax:574-647-8768
Practice Address - Street 1:69045 M-62
Practice Address - Street 2:SUITE A-1
Practice Address - City:EDWARDSBURG
Practice Address - State:MI
Practice Address - Zip Code:49112
Practice Address - Country:US
Practice Address - Phone:269-663-2201
Practice Address - Fax:269-663-2209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1578619078Medicaid
MI1578619078Medicaid