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General NPI Number Information
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NPI Number | 1124826011
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Entity Type | Organization
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Legal Business Name | PROSPEROUS HEALTH IMPERIAL BEACH, LLC
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Dates
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Enumeration Date | 03/05/2025
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Last Update Date | 06/23/2025
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Provider Practice Location Address
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Address Line | 107 DAISY AVE
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City | IMPERIAL BEACH
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State | CA
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Zip | 91932
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Country | US
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Telephone | 833-364-4722
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Fax |
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Provider Business Mailing Address
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Address Line | 9909 HUENNEKENS ST STE 110
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City | SAN DIEGO
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State | CA
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Zip | 92121-2928
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. JERRY SHIREY
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Credential |
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Telephone | 619-669-3295
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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