Healthcare Provider Details

I. General information

NPI: 1588853378
Provider Name (Legal Business Name): PRODIGY SOLUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 MCCULLOUGH DR. SUITE 120
CHARLOTTE NC
28262
US

IV. Provider business mailing address

416 MCCULLOUGH DR. SUITE 120
CHARLOTTE NC
28262
US

V. Phone/Fax

Practice location:
  • Phone: 704-231-4516
  • Fax: 704-919-5690
Mailing address:
  • Phone: 704-971-4270
  • Fax: 704-971-3274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. LUTHER SHERARD DOUGLAS
Title or Position: PRESIDENT
Credential:
Phone: 704-231-4516