Basic Information
| Provider Information | |||||||||
| NPI: | 1821705237 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRUITTHEALTH - NORTH TAMPA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1626 JEURGENS CT | ||||||||
| Address2: | ATTN: LEGAL DEPT | ||||||||
| City: | NORCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702796200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18940 SUNLAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | LUTZ | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335584943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702966200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2022 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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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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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.