Provider Demographics
NPI:1851645840
Name:PRODIGY DIALYSIS
Entity Type:Organization
Organization Name:PRODIGY DIALYSIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CORY
Authorized Official - Middle Name:
Authorized Official - Last Name:YACYNYCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-299-4676
Mailing Address - Street 1:88 OSBORNE ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4146
Mailing Address - Country:US
Mailing Address - Phone:814-539-0798
Mailing Address - Fax:814-536-4751
Practice Address - Street 1:211 THOMPSON ST
Practice Address - Street 2:
Practice Address - City:SEWARD
Practice Address - State:PA
Practice Address - Zip Code:15954-2053
Practice Address - Country:US
Practice Address - Phone:814-539-0798
Practice Address - Fax:814-536-4751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042825E261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment