Provider Demographics
NPI:1265158661
Name:PRODIGY HEALTHCARE NON PROFIT
Entity type:Organization
Organization Name:PRODIGY HEALTHCARE NON PROFIT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAGDIP
Authorized Official - Middle Name:
Authorized Official - Last Name:DHANDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-892-9452
Mailing Address - Street 1:311 E MERCED ST
Mailing Address - Street 2:
Mailing Address - City:FOWLER
Mailing Address - State:CA
Mailing Address - Zip Code:93625-2316
Mailing Address - Country:US
Mailing Address - Phone:559-892-9452
Mailing Address - Fax:
Practice Address - Street 1:311 E MERCED ST
Practice Address - Street 2:
Practice Address - City:FOWLER
Practice Address - State:CA
Practice Address - Zip Code:93625-2316
Practice Address - Country:US
Practice Address - Phone:559-892-9452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health