Provider Demographics
NPI:1386267490
Name:A PRODIGAL'S PATH 2 RECOVERY, INC.
Entity type:Organization
Organization Name:A PRODIGAL'S PATH 2 RECOVERY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:LOYD
Authorized Official - Last Name:STALLINGS
Authorized Official - Suffix:
Authorized Official - Credentials:LADAC II, MAC
Authorized Official - Phone:865-730-6628
Mailing Address - Street 1:107 PAINT ROCK FERRY RD
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763-2921
Mailing Address - Country:US
Mailing Address - Phone:865-730-6628
Mailing Address - Fax:865-730-6792
Practice Address - Street 1:107 PAINT ROCK FERRY RD
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:TN
Practice Address - Zip Code:37763-2921
Practice Address - Country:US
Practice Address - Phone:865-730-6628
Practice Address - Fax:865-730-6792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-22
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty