Provider Demographics
NPI:1760017701
Name:PROSPER ADOLESCENT CARE LLC
Entity Type:Organization
Organization Name:PROSPER ADOLESCENT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BAISDEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:406-890-5885
Mailing Address - Street 1:6885 BAUMAN ST
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-8723
Mailing Address - Country:US
Mailing Address - Phone:855-383-2566
Mailing Address - Fax:
Practice Address - Street 1:31733 S FORK YAAK RD STE B
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MT
Practice Address - Zip Code:59935-8681
Practice Address - Country:US
Practice Address - Phone:855-383-2566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility