Healthcare Provider Details

I. General information

NPI: 1245037019
Provider Name (Legal Business Name): PROSPEROUS HEALTH SAN DIEGO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2025
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9909 HUENNEKENS ST STE 110
SAN DIEGO CA
92121-2928
US

IV. Provider business mailing address

9909 HUENNEKENS ST STE 110
SAN DIEGO CA
92121-2928
US

V. Phone/Fax

Practice location:
  • Phone: 619-669-3295
  • Fax:
Mailing address:
  • Phone: 858-500-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. GERALD R SHIREY III
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 858-500-8000