Provider Demographics
NPI:1407894504
Name:PRUITTHEALTH HOSPICE, INC.
Entity Type:Organization
Organization Name:PRUITTHEALTH HOSPICE, INC.
Other - Org Name:PRUITTHEALTH HOSPICE - COBB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN & CEO OF MGR
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:
Practice Address - Street 1:1676 MULKEY ROAD
Practice Address - Street 2:SUITES 103
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1170
Practice Address - Country:US
Practice Address - Phone:770-916-4503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA111623Medicare Oscar/Certification