Provider Demographics
NPI:1497051627
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:MR
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:888-885-5580
Mailing Address - Fax:888-885-5580
Practice Address - Street 1:311 E MERCED ST
Practice Address - Street 2:(ROOMS 1-7 , CONFERENCE ROOM )
Practice Address - City:FOWLER
Practice Address - State:CA
Practice Address - Zip Code:93625-2316
Practice Address - Country:US
Practice Address - Phone:888-885-5580
Practice Address - Fax:888-885-5580
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRODIGY HEALTHCARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-05
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGOtherMEDI-CAL