Organization
BEACON HEALTH VENTURES INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFERY COSTELLO (CFO)
(574) 647-8545
Entity
Organization
Contact information
Practice address
900 I ST, LA PORTE, IN 46350-5533
(219) 324-1775
Mailing address
3355 DOUGLAS ROAD, SOUTH BEND, IN 46635-1780
(574) 647-2273
(574) 647-8768
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
69000135A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000363708
ANTHEM PROVIDER
IN
05
—
200253800A
—
IN
Enumeration date
11/13/2006
Last updated
04/19/2018
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