Provider Demographics
NPI:1255002812
Name:PROSPERA HEALTHCARE MICHIGAN LLC
Entity Type:Organization
Organization Name:PROSPERA HEALTHCARE MICHIGAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CODDINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-900-2488
Mailing Address - Street 1:5200 SADDLE DR
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-6011
Mailing Address - Country:US
Mailing Address - Phone:972-900-2488
Mailing Address - Fax:
Practice Address - Street 1:402 W 2ND ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1904
Practice Address - Country:US
Practice Address - Phone:248-770-9929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health