Basic Information
Provider Information | |||||||||
NPI: | 1184860306 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRUITTHEALTH HOSPICE, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PRUITTHEALTH HOSPICE - SIMPSONVILLE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1626 JEURGENS COURT | ||||||||
Address2: |   | ||||||||
City: | NORCROSS | ||||||||
State: | GA | ||||||||
PostalCode: | 300932219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7702796200 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 102 EAST CURTIS STREET | ||||||||
Address2: |   | ||||||||
City: | SIMPSONVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296812620 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8649626699 | ||||||||
FaxNumber: | 8649626816 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/17/2008 | ||||||||
LastUpdateDate: | 07/07/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PRUITT | ||||||||
AuthorizedOfficialFirstName: | NEIL | ||||||||
AuthorizedOfficialMiddleName: | L. | ||||||||
AuthorizedOfficialTitleorPosition: | CHAIRMAN AND CEO | ||||||||
AuthorizedOfficialTelephone: | 7702796200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X |   |   | Y |   | Agencies | Hospice Care, Community Based |   |
No ID Information.