Provider Demographics
NPI:1407695224
Name:PROSPER HEALTH LLC
Entity type:Organization
Organization Name:PROSPER HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHESTER
Authorized Official - Middle Name:
Authorized Official - Last Name:LACKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-757-0337
Mailing Address - Street 1:675 JEFFERSON AVE # B
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3729
Mailing Address - Country:US
Mailing Address - Phone:208-805-9503
Mailing Address - Fax:
Practice Address - Street 1:1345 HILINE RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2943
Practice Address - Country:US
Practice Address - Phone:208-757-0337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit