Basic Information
Provider Information | |||||||||
NPI: | 1467409987 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRUITTHEALTH - OLD CAPITOL, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PRUITTHEALTH - OLD CAPITOL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1626 JEURGENS CT | ||||||||
Address2: | LEGAL DEPT | ||||||||
City: | NORCROSS | ||||||||
State: | GA | ||||||||
PostalCode: | 300932219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6785336485 | ||||||||
FaxNumber: | 7709315278 | ||||||||
Practice Location | |||||||||
Address1: | 310 HIGHWAY 1 BYPASS | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 304346432 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4786253741 | ||||||||
FaxNumber: | 4786259473 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/29/2006 | ||||||||
LastUpdateDate: | 04/07/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PRUITT | ||||||||
AuthorizedOfficialFirstName: | NEIL | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | CHAIRMAN AND CEO OF MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7702796200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1-081-1569 | GA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 00142304A | 05 | GA |   | MEDICAID |