Provider Demographics
NPI:1235373382
Name:PRODIGY HOME HEALTH
Entity Type:Organization
Organization Name:PRODIGY HOME HEALTH
Other - Org Name:PRODIGY HOMEMAKERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:AMUZU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-267-0032
Mailing Address - Street 1:16945 GLEN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60478-2149
Mailing Address - Country:US
Mailing Address - Phone:708-267-0032
Mailing Address - Fax:
Practice Address - Street 1:7601 COBB LN
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32534-4264
Practice Address - Country:US
Practice Address - Phone:850-475-1859
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-20
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL690055196Medicaid