Provider Demographics
NPI:1700928603
Name:PRODIGY FOUNDATION
Entity Type:Organization
Organization Name:PRODIGY FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:B
Authorized Official - Last Name:AVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-456-8399
Mailing Address - Street 1:1024 S MUSKOGEE AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4734
Mailing Address - Country:US
Mailing Address - Phone:918-456-8399
Mailing Address - Fax:918-456-8773
Practice Address - Street 1:1024 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4734
Practice Address - Country:US
Practice Address - Phone:918-456-8399
Practice Address - Fax:918-456-8773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health