Healthcare Provider Details

I. General information

NPI: 1083362065
Provider Name (Legal Business Name): PROSPER DDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4043 E 530 N
RIGBY ID
83442-4948
US

IV. Provider business mailing address

4043 E 530 N
RIGBY ID
83442-4948
US

V. Phone/Fax

Practice location:
  • Phone: 208-270-1309
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: KIM BERGER
Title or Position: ACCOUNT ADMINISTRATOR
Credential:
Phone: 208-270-1309