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General NPI Number Information
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NPI Number | 1760017701
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Entity Type | Organization
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Legal Business Name | PROSPER ADOLESCENT CARE LLC
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Dates
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Enumeration Date | 03/10/2020
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Last Update Date | 03/10/2020
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Provider Practice Location Address
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Address Line | 31733 S FORK YAAK RD STE B
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City | TROY
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State | MT
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Zip | 59935-8681
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Country | US
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Telephone | 855-383-2566
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Fax |
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Provider Business Mailing Address
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Address Line | 6885 BAUMAN ST
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City | BONNERS FERRY
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State | ID
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Zip | 83805-8723
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Country | US
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Telephone | 855-383-2566
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Fax |
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Authorized Official
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Title or Position | PARTNER
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Name | JOHN WILLIAM BAISDEN JR.
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Credential |
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Telephone | 406-890-5885
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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License Number |
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License Number State |
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