1164554432 NPI number — PRUITTHEALTH HOME FIRST, INC.

Table of content: (NPI 1164554432)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164554432 NPI number — PRUITTHEALTH HOME FIRST, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRUITTHEALTH HOME FIRST, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164554432
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1626 JEURGENS COURT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORCROSS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30093-2219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-279-6200
Provider Business Mailing Address Fax Number:
706-827-2048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6050 APPALACHIAN HIGHWAY
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
BLUE RIDGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-632-9263
Provider Business Practice Location Address Fax Number:
706-632-0028
Provider Enumeration Date:
03/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PRUITT
Authorized Official First Name:
NEIL
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CHAIRMAN AND CEO
Authorized Official Telephone Number:
770-279-6200

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 300036015B . This is a "MEDICAID PAVEE #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 8550800G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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