Provider Demographics
NPI:1922401496
Name:PRONGHORN PSYCHIATRY
Entity Type:Organization
Organization Name:PRONGHORN PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:775-335-9932
Mailing Address - Street 1:5940 E. COPPER HILL DR.
Mailing Address - Street 2:STE. B
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314
Mailing Address - Country:US
Mailing Address - Phone:928-583-7799
Mailing Address - Fax:928-583-7891
Practice Address - Street 1:5940 E. COPPER HILL DR.
Practice Address - Street 2:STE. B
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314
Practice Address - Country:US
Practice Address - Phone:928-583-7799
Practice Address - Fax:928-583-7891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-29
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZIFBH6794283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital