Provider Demographics
NPI:1194128934
Name:CONRAD HEALTHCARE LLC
Entity type:Organization
Organization Name:CONRAD HEALTHCARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-292-6754
Mailing Address - Street 1:3390 TAMIAMI TRL
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-8157
Mailing Address - Country:US
Mailing Address - Phone:941-787-5619
Mailing Address - Fax:941-787-5618
Practice Address - Street 1:3390 TAMIAMI TRL
Practice Address - Street 2:SUITE 203
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8157
Practice Address - Country:US
Practice Address - Phone:941-787-5619
Practice Address - Fax:941-787-5618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-08
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL299994379OtherHOME HEALTH AGENCY LICENSE