Provider Demographics
NPI:1487379236
Name:PRODIGIOUS INC
Entity type:Organization
Organization Name:PRODIGIOUS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VALENCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-563-0137
Mailing Address - Street 1:6707 CHAPARRAL DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-3105
Mailing Address - Country:US
Mailing Address - Phone:470-275-4896
Mailing Address - Fax:
Practice Address - Street 1:1103 GALVIN RD S STE L 1/2
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-3002
Practice Address - Country:US
Practice Address - Phone:470-275-4896
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies