Provider Demographics
NPI:1124791587
Name:THE SOUTH BEND CLINIC LLC
Entity type:Organization
Organization Name:THE SOUTH BEND CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:301 E DAY RD
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3455
Mailing Address - Country:US
Mailing Address - Phone:574-259-9668
Mailing Address - Fax:
Practice Address - Street 1:301 E DAY RD
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3455
Practice Address - Country:US
Practice Address - Phone:574-299-2450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-30
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies