Basic Information
Provider Information | |||||||||
NPI: | 1366789505 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRUITTHEALTH - MARIETTA, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PRUITTHEALTH - MARIETTA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1626 JEURGENS CT | ||||||||
Address2: |   | ||||||||
City: | NORCROSS | ||||||||
State: | GA | ||||||||
PostalCode: | 300932219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7702796200 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 50 SAINE DR SW | ||||||||
Address2: |   | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300083824 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704298600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/08/2013 | ||||||||
LastUpdateDate: | 06/27/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PRUITT | ||||||||
AuthorizedOfficialFirstName: | NEIL | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | CHAIRMAN AND CEO OF MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7702796200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1-033-1793 | GA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.