Healthcare Provider Details

I. General information

NPI: 1629659578
Provider Name (Legal Business Name): PROSPER INTEGRATED HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10750 W MCDOWELL RD STE C305
AVONDALE AZ
85392-5964
US

IV. Provider business mailing address

PO BOX 5135
SUN CITY WEST AZ
85376-5135
US

V. Phone/Fax

Practice location:
  • Phone: 623-755-5679
  • Fax:
Mailing address:
  • Phone: 860-690-5309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MRS. ELONDA WILSON
Title or Position: COO
Credential:
Phone: 860-690-5309