Basic Information
| Provider Information | |||||||||
| NPI: | 1386154821 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEACON HEALTH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 N NILES AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466171924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471610 | ||||||||
| FaxNumber: | 5742376069 | ||||||||
| Practice Location | |||||||||
| Address1: | 3221 BEACON PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | GRANGER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465307196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746472930 | ||||||||
| FaxNumber: | 5746472935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2017 | ||||||||
| LastUpdateDate: | 03/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | COSTELLO | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | PETER | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5746473460 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.