Basic Information
| Provider Information | |||||||||
| NPI: | 1174504203 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRUITTHEALTH - ESTILL, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRUITTHEALTH - ESTILL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1626 JEURGENS CT | ||||||||
| Address2: | |||||||||
| City: | NORCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300932219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702796200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 252 LIBERTY STREET SOUTH | ||||||||
| Address2: | |||||||||
| City: | ESTILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299183311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8036253852 | ||||||||
| FaxNumber: | 8036252441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 06/30/2014 | ||||||||
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| AuthorizedOfficialLastName: | PRUITT | ||||||||
| AuthorizedOfficialFirstName: | NEIL | ||||||||
| AuthorizedOfficialMiddleName: | LITTLE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN/CEO OF MGR | ||||||||
| AuthorizedOfficialTelephone: | 7702796200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NCF922 | SC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0585NH | 05 | SC | MEDICAID |