Provider Demographics
NPI:1013662717
Name:PRODIGAL MINISTRIES, LLC
Entity type:Organization
Organization Name:PRODIGAL MINISTRIES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RECONCILIATION DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NINA
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-585-4306
Mailing Address - Street 1:PO BOX 1484
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-1484
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4414 OLD LAGRANGE RD
Practice Address - Street 2:
Practice Address - City:BUCKNER
Practice Address - State:KY
Practice Address - Zip Code:40010-9547
Practice Address - Country:US
Practice Address - Phone:502-222-2389
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-21
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Single Specialty