Healthcare Provider Details

I. General information

NPI: 1093017931
Provider Name (Legal Business Name): PRODIGIOUS HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2010
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 S BRAGG ST
WARRENTON NC
27589-2048
US

IV. Provider business mailing address

108 SOUTH BRAGG STREET
WARRENTON NC
27589-2048
US

V. Phone/Fax

Practice location:
  • Phone: 252-257-6500
  • Fax: 252-257-6700
Mailing address:
  • Phone: 252-433-0300
  • Fax: 252-433-8054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number101Y00000X
License Number StateNC

VIII. Authorized Official

Name: MR. BOBBY FAISON
Title or Position: PRESIDENT
Credential: MS
Phone: 252-433-0300