Provider Demographics
NPI:1336196468
Name:PRUITTHEALTH - BROOKHAVEN, LLC
Entity Type:Organization
Organization Name:PRUITTHEALTH - BROOKHAVEN, LLC
Other - Org Name:PRUITTHEALTH - BROOKHAVEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN & CEO OF MGR
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:706-827-2048
Practice Address - Street 1:3535 ASHTON WOODS DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30319-2201
Practice Address - Country:US
Practice Address - Phone:770-451-0236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-044-1768314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00140115AMedicaid
GA115313Medicare Oscar/Certification