Provider Demographics
NPI:1700299922
Name:PRUITTHEALTH - SYLVESTER, LLC
Entity Type:Organization
Organization Name:PRUITTHEALTH - SYLVESTER, LLC
Other - Org Name:PRUITTHEALTH - SYLVESTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN & CEO OF MANAGER
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:770-931-5278
Practice Address - Street 1:104 MONK ST
Practice Address - Street 2:
Practice Address - City:SYLVESTER
Practice Address - State:GA
Practice Address - Zip Code:31791-7246
Practice Address - Country:US
Practice Address - Phone:229-776-5541
Practice Address - Fax:229-776-9712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
115629Medicare Oscar/Certification