Healthcare Provider Details

I. General information

NPI: 1700377983
Provider Name (Legal Business Name): PRONGHORN PSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 11/15/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5940 E. COPPER HILL DR SUITE E
PRESCOTT VALLEY AZ
86314
US

IV. Provider business mailing address

5940 E. COPPER HILL DR SUITE E
PRESCOTT VALLEY AZ
86314
US

V. Phone/Fax

Practice location:
  • Phone: 928-583-7799
  • Fax: 928-583-7891
Mailing address:
  • Phone: 928-583-7799
  • Fax: 928-583-7891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberOTC8169
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH LETENDRE
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 928-583-7799