Provider Demographics
NPI:1699777417
Name:ENDEAVOR THERAPY LLC
Entity type:Organization
Organization Name:ENDEAVOR THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:BLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-241-8892
Mailing Address - Street 1:11649 N PORT WASHINGTON RD
Mailing Address - Street 2:STE 109
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3460
Mailing Address - Country:US
Mailing Address - Phone:262-241-8892
Mailing Address - Fax:262-241-8894
Practice Address - Street 1:11649 N PORT WASHINGTON RD
Practice Address - Street 2:STE 109
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3460
Practice Address - Country:US
Practice Address - Phone:262-241-8892
Practice Address - Fax:262-241-8894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-11
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40076000Medicaid
524505Medicare ID - Type Unspecified