Provider Demographics
NPI:1770740086
Name:PRUITTHEALTH HOSPICE, INC.
Entity type:Organization
Organization Name:PRUITTHEALTH HOSPICE, 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 COURT
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:706-886-8493
Mailing Address - Fax:706-886-0542
Practice Address - Street 1:7345 RED OAK ROAD
Practice Address - Street 2:BUILDING 25
Practice Address - City:UNION CITY
Practice Address - State:GA
Practice Address - Zip Code:30291-2391
Practice Address - Country:US
Practice Address - Phone:770-254-8612
Practice Address - Fax:770-254-8605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA111677Medicare Oscar/Certification