Healthcare Provider Details

I. General information

NPI: 1376313973
Provider Name (Legal Business Name): PRODIGAL MINISTRIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 MAIN ST STE B
FLORENCE KY
41042-2050
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: 502-222-2389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

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