Provider Demographics
NPI:1124826011
Name:PROSPEROUS HEALTH SAN DIEGO, LLC
Entity type:Organization
Organization Name:PROSPEROUS HEALTH SAN DIEGO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF DEVELOPMENT OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-669-3295
Mailing Address - Street 1:9909 HUENNEKENS ST STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-2928
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4232 SHARRON PL
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-6019
Practice Address - Country:US
Practice Address - Phone:619-669-3295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder