MEDICARE: PRODIGY HEALTH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1326787268
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRODIGY HEALTH LLC

Provider Business Mailing Address
First Line	:	410 S WARE BLVD STE 815
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33619-4456
Country	:	US
Telephone Number	:	813-492-0370
Fax Number	:	813-374-4546

Provider Business Practice Location Address
First Line	:	410 S WARE BLVD STE 815
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33619-4456
Country	:	US
Telephone Number	:	813-492-0370
Fax Number	:	813-374-4546

Authorized Official
Title or Position	:	OWNER, CEO
Name	:	DR. JUSTIN ALBERTO RIOS
Credential	:	DC
Telephone Number	:	813-492-0370

Provider Enumeration Date	:	05/31/2022
Last Update Date	:	06/30/2022

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