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General NPI Number Information
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NPI Number | 1255002812
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Entity Type | Organization
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Legal Business Name | PROSPERA HEALTHCARE MICHIGAN LLC
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Dates
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Enumeration Date | 09/23/2021
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Last Update Date | 09/23/2021
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Provider Practice Location Address
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Address Line | 402 W 2ND ST
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City | ROCHESTER
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State | MI
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Zip | 48307-1904
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Country | US
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Telephone | 248-770-9929
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Fax |
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Provider Business Mailing Address
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Address Line | 5200 SADDLE DR
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City | FLOWER MOUND
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State | TX
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Zip | 75028-6011
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Country | US
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Telephone | 972-900-2488
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Fax |
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Authorized Official
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Title or Position | COO
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Name | KYLE CODDINGTON
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Credential |
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Telephone | 972-900-2488
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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