Basic Information
| Provider Information | |||||||||
| NPI: | 1710010715 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRUITTHEALTH - BLUE RIDGE LLC | ||||||||
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| OtherOrganizationName: | PRUITTHEALTH COMMUNITY SERVICES - BLUE RIDGE | ||||||||
| 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: | 74 OUIDA STREET | ||||||||
| Address2: | |||||||||
| City: | BLUE RIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062582819 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 06/30/2014 | ||||||||
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| AuthorizedOfficialLastName: | PRUITT | ||||||||
| AuthorizedOfficialFirstName: | NEIL | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 7702796200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311ZA0620X | Y | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
ID Information
| ID | Type | State | Issuer | Description | 00140973A | 05 | GA | MEDICAID |