Basic Information
| Provider Information | |||||||||
| NPI: | 1720309933 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRUITTHEALTH - RALEIGH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1626 JEURGENS COURT | ||||||||
| Address2: | LEGAL DEPT | ||||||||
| City: | NORCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300932219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197550226 | ||||||||
| FaxNumber: | 9197550313 | ||||||||
| Practice Location | |||||||||
| Address1: | 2420 LAKE WHEELER RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276032614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197550226 | ||||||||
| FaxNumber: | 9197550313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2010 | ||||||||
| LastUpdateDate: | 09/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | PRUITT | ||||||||
| AuthorizedOfficialFirstName: | NEIL | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 9197550226 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRUITTHEALTH - RALEIGH, LLC | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH0618 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.