| Organization Name: | PRODIGY HEALTHCARE, INC. |
| NPI Number: | 1710284229 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JAGDIP DHANDA (CEO) |
| Mailing Address: | 701 E Main St (rooms 104, 501, 701) Fowler |
| State: | CA US |
| Postal Code: | 936252423 |
| Phone Number: | 8888855580 |
| Fax Number: | 8888855580 |
| NPI Enumeration Date: | 02/17/2011 |
| NPI Last Update Date: | 06/28/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QR0405X |
| License Number: | PENDING |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Rehabilitation, Substance Use Disorder |
| Taxonomy Definition: | |