Provider Demographics
NPI:1245278407
Name:PRUITTHEALTH HOME HEALTH - SOUTH ATLANTA, INC.
Entity type:Organization
Organization Name:PRUITTHEALTH HOME HEALTH - SOUTH ATLANTA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN AND CEO
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:LEGAL DEPT
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 1:147 W ELLIS RD
Practice Address - Street 2:SUITES B & C
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-7147
Practice Address - Country:US
Practice Address - Phone:770-228-0525
Practice Address - Fax:770-228-0894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA126-283-H251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00709816AMedicaid
GA00709816AMedicaid