Provider Demographics
NPI:1700074564
Name:PRUITTHEALTH - MONCKS CORNER LLC
Entity Type:Organization
Organization Name:PRUITTHEALTH - MONCKS CORNER LLC
Other - Org Name:PRUITTHEALTH - MONCKS CORNER
Other - Org Type:Doing Business As
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:
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 1:505 S LIVE OAK DRIVE
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3553
Practice Address - Country:US
Practice Address - Phone:843-761-8368
Practice Address - Fax:843-761-5874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0855NFMedicaid
SC425140Medicare Oscar/Certification