Basic Information
| Provider Information | |||||||||
| NPI: | 1043899321 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRUITTHEALTH HOME HEALTH - SOUTH ATLANTA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1626 JEURGENS COURT | ||||||||
| Address2: | LEGAL DEPT | ||||||||
| City: | NORCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300932219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702796200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6060 LAKESIDE COMMONS DRIVE | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702796200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2021 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | CLEMENTS | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR CORPORATE PARALEGAL | ||||||||
| AuthorizedOfficialTelephone: | 6785336395 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRUITTHEALTH HOME HEALTH - SOUTH ATLANTA, INC. | ||||||||
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| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
No ID Information.