1235373382 NPI number — PRODIGY HOME HEALTH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235373382 NPI number — PRODIGY HOME HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRODIGY HOME HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235373382
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16945 GLEN OAKS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COUNTRY CLUB HILLS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60478-2149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-267-0032
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7601 COBB LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32534-4264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-475-1859
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/20/2009

Additional Information

Authorized Official

Authorized Official Last Name:
AMUZU
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
708-267-0032

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 690055196 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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