Basic Information
Provider Information | |||||||||
NPI: | 1962459487 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRUITTHEALTH - LAFAYETTE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PRUITTHEALTH - LAFAYETTE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1626 JEURGENS CT | ||||||||
Address2: |   | ||||||||
City: | NORCROSS | ||||||||
State: | GA | ||||||||
PostalCode: | 300932219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7702796200 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 205 ROADRUNNER BLVD | ||||||||
Address2: |   | ||||||||
City: | LA FAYETTE | ||||||||
State: | GA | ||||||||
PostalCode: | 307282161 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7066384662 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/29/2006 | ||||||||
LastUpdateDate: | 07/02/2014 | ||||||||
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: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1-146-1721 | GA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 00254394A | 05 | GA |   | MEDICAID |