Provider Demographics
NPI:1750841367
Name:BLACKBIRD ENDEAVORS, LLC
Entity Type:Organization
Organization Name:BLACKBIRD ENDEAVORS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:CROFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-594-1067
Mailing Address - Street 1:504 BROAD ST APT 5
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-2675
Mailing Address - Country:US
Mailing Address - Phone:706-594-1067
Mailing Address - Fax:
Practice Address - Street 1:102 MAIN ST STE 203
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3225
Practice Address - Country:US
Practice Address - Phone:335-942-2738
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care