Basic Information
| Provider Information | |||||||||
| NPI: | 1144617176 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRODIGY HEALTHCARE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 820 | ||||||||
| Address2: | |||||||||
| City: | FOWLER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936250820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5598929452 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2580 W TAHOE AVE | ||||||||
| Address2: | |||||||||
| City: | CARUTHERS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936099475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5598929452 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2015 | ||||||||
| LastUpdateDate: | 04/16/2015 | ||||||||
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| AuthorizedOfficialLastName: | DHANDA | ||||||||
| AuthorizedOfficialFirstName: | JAGDIP | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5598929452 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRODIGY HEALTHCARE, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.