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General NPI Number Information
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NPI Number | 1487379236
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Entity Type | Organization
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Legal Business Name | PRODIGIOUS INC
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Dates
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Enumeration Date | 10/04/2022
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Last Update Date | 10/04/2022
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Provider Practice Location Address
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Address Line | 1103 GALVIN RD S STE L 1/2
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City | BELLEVUE
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State | NE
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Zip | 68005-3002
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Country | US
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Telephone | 470-275-4896
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Fax |
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Provider Business Mailing Address
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Address Line | 6707 CHAPARRAL DR
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City | LITHONIA
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State | GA
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Zip | 30038-3105
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Country | US
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Telephone | 470-275-4896
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | VALENCIA ELLIOTT
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Credential |
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Telephone | 404-563-0137
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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