Provider Demographics
NPI:1477816080
Name:BEACON HEALTH VENTURES INC
Entity type:Organization
Organization Name:BEACON HEALTH VENTURES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-647-8777
Mailing Address - Street 1:3355 DOUGLAS RD
Mailing Address - Street 2:SUITE 100
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 ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-9315
Practice Address - Country:US
Practice Address - Phone:574-524-7582
Practice Address - Fax:574-524-7597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No251F00000XAgenciesHome Infusion
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158807OtherPK
IN100301140CMedicaid
2158807OtherPK