Provider Demographics
NPI:1194907048
Name:PROSPERITY HEALTH SERVICES, LLC
Entity type:Organization
Organization Name:PROSPERITY HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLEOTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-296-1901
Mailing Address - Street 1:1615 N HAMPTON RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-8303
Mailing Address - Country:US
Mailing Address - Phone:972-296-1901
Mailing Address - Fax:972-296-5590
Practice Address - Street 1:1615 N HAMPTON RD
Practice Address - Street 2:SUITE 130
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-8303
Practice Address - Country:US
Practice Address - Phone:972-296-1901
Practice Address - Fax:972-296-5590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX011923251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX453189OtherMEDICARE