Healthcare Provider Details

I. General information

NPI: 1073477725
Provider Name (Legal Business Name): PRODIGIOUS STAFFING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31221 LYNDON ST
LIVONIA MI
48154-4354
US

IV. Provider business mailing address

31221 LYNDON ST
LIVONIA MI
48154-4354
US

V. Phone/Fax

Practice location:
  • Phone: 734-407-7622
  • Fax:
Mailing address:
  • Phone: 734-407-7622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: GAVIN RISER
Title or Position: GENERAL MANAGER
Credential:
Phone: 734-407-7622