1316243546 NPI number — PRODIGY HEALTHCARE, INC.

Table of content: (NPI 1316243546)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316243546 NPI number — PRODIGY HEALTHCARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRODIGY HEALTHCARE, INC.
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:
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:
1316243546
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 820
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOWLER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93625-0820
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-885-5580
Provider Business Mailing Address Fax Number:
888-885-5580

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1976 MORRIS KYLE DR
Provider Second Line Business Practice Location Address:
(MO,101-2,301-5,404,501-5,601-5,701-3,801-14,901-7,CO)
Provider Business Practice Location Address City Name:
FIREBAUGH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93622-9711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-885-5580
Provider Business Practice Location Address Fax Number:
888-885-5580
Provider Enumeration Date:
02/05/2011

Additional Information

Authorized Official

Authorized Official Last Name:
DHANDA
Authorized Official First Name:
JAGDIP
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
559-892-9452

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PENDING . This is a "MEDI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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