Provider Demographics
NPI:1952897712
Name:PRIDHAM LLC
Entity Type:Organization
Organization Name:PRIDHAM LLC
Other - Org Name:HEALTHSOURCE OF CASPER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NINA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIDHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-703-6120
Mailing Address - Street 1:426 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2408
Mailing Address - Country:US
Mailing Address - Phone:307-266-6908
Mailing Address - Fax:307-266-2583
Practice Address - Street 1:426 W 1ST ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2408
Practice Address - Country:US
Practice Address - Phone:307-266-6908
Practice Address - Fax:307-266-2583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY772111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty