Provider Demographics
NPI:1144617176
Name:PRODIGY HEALTHCARE, INC.
Entity Type:Organization
Organization Name:PRODIGY HEALTHCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAGDIP
Authorized Official - Middle Name:
Authorized Official - Last Name:DHANDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-892-9452
Mailing Address - Street 1:PO BOX 820
Mailing Address - Street 2:
Mailing Address - City:FOWLER
Mailing Address - State:CA
Mailing Address - Zip Code:93625-0820
Mailing Address - Country:US
Mailing Address - Phone:559-892-9452
Mailing Address - Fax:
Practice Address - Street 1:2580 W TAHOE AVE
Practice Address - Street 2:
Practice Address - City:CARUTHERS
Practice Address - State:CA
Practice Address - Zip Code:93609-9475
Practice Address - Country:US
Practice Address - Phone:559-892-9452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRODIGY HEALTHCARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder