Basic Information
| Provider Information | |||||||||
| NPI: | 1649758012 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRUITTHEALTH - FLEMING ISLAND, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRUITTHEALTH - FLEMING ISLAND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1626 JEURGENS CT | ||||||||
| Address2: | |||||||||
| City: | NORCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300932219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702796200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2040 TOWN CENTER BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | FLEMING ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042931311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2018 | ||||||||
| LastUpdateDate: | 11/09/2018 | ||||||||
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| AuthorizedOfficialLastName: | PRUITT | ||||||||
| AuthorizedOfficialFirstName: | NEIL | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN & CEO OF MANAGER'S MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7702796200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.