Basic Information
| Provider Information | |||||||||
| NPI: | 1487164877 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRODIGY HEALTHCARE INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 E MERCED ST | ||||||||
| Address2: | |||||||||
| City: | FOWLER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936252316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5598929452 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3125 WRIGHT ST | ||||||||
| Address2: | |||||||||
| City: | SELMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936622429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5598929452 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | DHANDA | ||||||||
| AuthorizedOfficialFirstName: | JAGDIP | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5598929452 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.