Provider Demographics
NPI:1790241735
Name:CONGENIAL HEALTHCARE, LLC
Entity Type:Organization
Organization Name:CONGENIAL HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ENDERLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-712-1681
Mailing Address - Street 1:1 ROOSEVELT AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-2227
Mailing Address - Country:US
Mailing Address - Phone:978-536-0215
Mailing Address - Fax:978-536-0230
Practice Address - Street 1:1 ROOSEVELT AVE STE 201
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-2227
Practice Address - Country:US
Practice Address - Phone:978-740-2300
Practice Address - Fax:978-744-3993
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONGENIAL HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty