Basic Information
| Provider Information | |||||||||
| NPI: | 1386036473 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRUITTHEALTH HOSPICE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRUITTHEALTH HOSPICE - FAYETTEVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1626 JEURGENS CT | ||||||||
| Address2: | |||||||||
| City: | NORCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300932219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702796200 | ||||||||
| FaxNumber: | 7709315278 | ||||||||
| Practice Location | |||||||||
| Address1: | 2850 VILLAGE DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104831793 | ||||||||
| FaxNumber: | 9104834315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2015 | ||||||||
| LastUpdateDate: | 12/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | PRUITT | ||||||||
| AuthorizedOfficialFirstName: | NEIL | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 7702796200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315D00000X | Y | Nursing & Custodial Care Facilities | Hospice, Inpatient |
No ID Information.