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General NPI Number Information
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NPI Number | 1407695224
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Entity Type | Organization
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Legal Business Name | PROSPER HEALTH LLC
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Dates
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Enumeration Date | 05/21/2024
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Last Update Date | 05/21/2024
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Provider Practice Location Address
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Address Line | 1345 HILINE RD
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City | POCATELLO
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State | ID
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Zip | 83201-2943
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Country | US
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Telephone | 208-757-0337
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Fax |
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Provider Business Mailing Address
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Address Line | 675 JEFFERSON AVE # B
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City | POCATELLO
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State | ID
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Zip | 83201-3729
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Country | US
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Telephone | 208-805-9503
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CHESTER LACKEY
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Credential |
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Telephone | 208-757-0337
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 276400000X
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Taxonomy Name | Substance Use Disorder Rehabilitation Hospital Unit
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License Number |
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License Number State |
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