Healthcare Provider Details

I. General information

NPI: 1013662717
Provider Name (Legal Business Name): PRODIGAL MINISTRIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2022
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4414 OLD LAGRANGE RD
BUCKNER KY
40010-9547
US

IV. Provider business mailing address

PO BOX 1484
CRESTWOOD KY
40014-1484
US

V. Phone/Fax

Practice location:
  • Phone: 502-222-2389
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: NINA J ROY
Title or Position: RECONCILIATION DIRECTOR
Credential:
Phone: 270-585-4306