Provider Demographics
NPI:1013231794
Name:THE OAKS OF BLYTHEWOOD, INC.
Entity Type:Organization
Organization Name:THE OAKS OF BLYTHEWOOD, INC.
Other - Org Name:PRUITTHEALTH - BLYTHEWOOD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:L
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:770-279-6200
Mailing Address - Street 1:1626 JEURGENS CT
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-2219
Mailing Address - Country:US
Mailing Address - Phone:770-279-6200
Mailing Address - Fax:770-931-5278
Practice Address - Street 1:1075 HEATHER GREEN DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-0000
Practice Address - Country:US
Practice Address - Phone:803-382-2300
Practice Address - Fax:803-382-2301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-24
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCNCF0959314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNF1012Medicaid
SCNF1012Medicaid