Provider Demographics
NPI:1992876627
Name:BEACON HEALTH VENTURES INC
Entity type:Organization
Organization Name:BEACON HEALTH VENTURES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-647-8545
Mailing Address - Street 1:3355 DOUGLAS ROAD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1780
Mailing Address - Country:US
Mailing Address - Phone:574-647-2273
Mailing Address - Fax:574-647-8768
Practice Address - Street 1:900 I ST
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-5533
Practice Address - Country:US
Practice Address - Phone:219-324-1775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN69000135A332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000363708OtherANTHEM PROVIDER
IN200253800AMedicaid
IN000000363708OtherANTHEM PROVIDER