Organization
PRODIGY FOUNDATION
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. BARRY B. AVERETT (OFFICE MANAGER)
(918) 456-8399
Entity
Organization
Contact information
Practice address
1024 S MUSKOGEE AVE, TAHLEQUAH, OK 74464-4734
(918) 456-8399
(918) 456-8773
Mailing address
1024 S MUSKOGEE AVE, TAHLEQUAH, OK 74464-4734
(918) 456-8399
(918) 456-8773
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
Other
Enumeration date
02/14/2007
Last updated
08/22/2020
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