Basic Information
| Provider Information | |||||||||
| NPI: | 1174878342 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRUITTHEALTH HOSPICE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRUITTHEALTH HOSPICE - ANDERSON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1626 JEURGENS CT | ||||||||
| Address2: | LEGAL DEPT | ||||||||
| City: | NORCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300932219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702796200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1510 N FANT ST | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296214708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642261219 | ||||||||
| FaxNumber: | 8642268730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2012 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PRUITT | ||||||||
| AuthorizedOfficialFirstName: | NEIL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 7702796200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRUITTHEALTH HOSPICE, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | Y | Agencies | Hospice Care, Community Based |
No ID Information.