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General NPI Number Information
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NPI Number | 1720389182
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Entity Type | Organization
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Legal Business Name | PRODIGIOUS HEALTH SERVICES, LLC
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Dates
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Enumeration Date | 11/16/2010
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Last Update Date | 11/16/2010
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Provider Practice Location Address
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Address Line | 210 N MAIN ST
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City | ROXBORO
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State | NC
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Zip | 27573-5325
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Country | US
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Telephone | 252-433-0300
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Fax | 252-433-8054
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Provider Business Mailing Address
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Address Line | PO BOX 2120
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City | HENDERSON
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State | NC
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Zip | 27536-2120
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Country | US
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Telephone | 252-433-0300
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Fax | 252-433-8054
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. BOBBY FAISON
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Credential | MS
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Telephone | 252-433-0300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 875
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License Number State | NC
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