Provider Demographics
NPI:1982651402
Name:PRUITTHEALTH - MAGNOLIA MANOR, LLC
Entity Type:Organization
Organization Name:PRUITTHEALTH - MAGNOLIA MANOR, LLC
Other - Org Name:PRUITTHEALTH - MAGNOLIA MANOR
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:
Practice Address - Street 1:3003 VETERANS PARKWAY SOUTH
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31788-6705
Practice Address - Country:US
Practice Address - Phone:229-985-3422
Practice Address - Fax:229-985-0227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-29
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-035-1653314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00252007AMedicaid
GA115326Medicare Oscar/Certification