Basic Information
| Provider Information | |||||||||
| NPI: | 1982651402 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRUITTHEALTH - MAGNOLIA MANOR, LLC | ||||||||
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| OtherOrganizationName: | PRUITTHEALTH - MAGNOLIA MANOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1626 JEURGENS CT | ||||||||
| Address2: | |||||||||
| City: | NORCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300932219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702796200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3003 VETERANS PARKWAY SOUTH | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317886705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299853422 | ||||||||
| FaxNumber: | 2299850227 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2006 | ||||||||
| LastUpdateDate: | 06/30/2014 | ||||||||
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| AuthorizedOfficialLastName: | PRUITT | ||||||||
| AuthorizedOfficialFirstName: | NEIL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 7702796200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1-035-1653 | GA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00252007A | 05 | GA | MEDICAID |