Provider Demographics
NPI:1104069509
Name:THE PRUDENT HEALTHCARE AGENCY INC.
Entity type:Organization
Organization Name:THE PRUDENT HEALTHCARE AGENCY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MONDDE
Authorized Official - Middle Name:KELVIN
Authorized Official - Last Name:IYAMAH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:817-663-3456
Mailing Address - Street 1:2100 N HWY 360 STE 207A
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-1010
Mailing Address - Country:US
Mailing Address - Phone:469-999-0861
Mailing Address - Fax:469-999-0860
Practice Address - Street 1:2100 N HWY 360
Practice Address - Street 2:SUITE207B
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-1011
Practice Address - Country:US
Practice Address - Phone:469-999-0861
Practice Address - Fax:469-999-0860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-14
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2130064-01Medicaid
TX74-7352Medicare PIN