Provider Demographics
NPI:1104865138
Name:PRUITTHEALTH - RIDGEWAY, LLC
Entity Type:Organization
Organization Name:PRUITTHEALTH - RIDGEWAY, LLC
Other - Org Name:PRUITTHEALTH - RIDGEWAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN AND CEO OF MANAGER
Authorized Official - Prefix:
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 1:213 TANGLEWOOD COURT
Practice Address - Street 2:
Practice Address - City:RIDGEWAY
Practice Address - State:SC
Practice Address - Zip Code:29130-7100
Practice Address - Country:US
Practice Address - Phone:803-337-3211
Practice Address - Fax:803-337-8124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCNCF710314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0124NHMedicaid
SC425288Medicare Oscar/Certification