Provider Demographics
NPI:1295420743
Name:PRODIGY MEDICAL SERVICE INC
Entity type:Organization
Organization Name:PRODIGY MEDICAL SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEON
Authorized Official - Middle Name:
Authorized Official - Last Name:YAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-249-1755
Mailing Address - Street 1:29995 TECHNOLOGY DR UNIT A100
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-2632
Mailing Address - Country:US
Mailing Address - Phone:951-249-2755
Mailing Address - Fax:
Practice Address - Street 1:406 9TH AVE STE 307
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-7278
Practice Address - Country:US
Practice Address - Phone:619-630-0125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service