Provider Demographics
NPI:1851064232
Name:THE SOUTH BEND CLINIC LLC
Entity Type:Organization
Organization Name:THE SOUTH BEND CLINIC LLC
Other - Org Name:THE SOUTH BEND CLINIC NEW CARLISLE
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HILER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-239-1567
Mailing Address - Street 1:6301 UNIVERSITY COMMONS STE 230
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1590
Mailing Address - Country:US
Mailing Address - Phone:574-239-1567
Mailing Address - Fax:
Practice Address - Street 1:8984 E US HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:NEW CARLISLE
Practice Address - State:IN
Practice Address - Zip Code:46552-9038
Practice Address - Country:US
Practice Address - Phone:574-654-8490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-30
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies