Healthcare Provider Details

I. General information

NPI: 1699777417
Provider Name (Legal Business Name): ENDEAVOR THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 06/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11649 N PORT WASHINGTON RD STE 109
MEQUON WI
53092-3460
US

IV. Provider business mailing address

11649 N PORT WASHINGTON RD STE 109
MEQUON WI
53092-3460
US

V. Phone/Fax

Practice location:
  • Phone: 262-241-8892
  • Fax: 262-241-8894
Mailing address:
  • Phone: 262-241-8892
  • Fax: 262-241-8894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State

VIII. Authorized Official

Name: MRS. KAREN IRENE BLOCK
Title or Position: ADMINISTRATOR
Credential:
Phone: 262-241-8892