Healthcare Provider Details

I. General information

NPI: 1346587607
Provider Name (Legal Business Name): LISA PENDERGAST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 01/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

497 BELLEVILLE AVE
NEW BEDFORD MA
02746-5432
US

IV. Provider business mailing address

497 BELLEVILLE AVE
NEW BEDFORD MA
02746-5432
US

V. Phone/Fax

Practice location:
  • Phone: 774-628-1000
  • Fax: 508-997-0765
Mailing address:
  • Phone: 774-628-1000
  • Fax: 508-997-0765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: