1235177205 NPI number — PRUITTHEALTH HOSPICE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235177205 NPI number — PRUITTHEALTH HOSPICE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRUITTHEALTH HOSPICE, 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:
1235177205
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1626 JEURGENS CT
Provider Second Line Business Mailing Address:
LEGAL DEPT
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:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6060 LAKESIDE COMMONS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31210-5778
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-745-9204
Provider Business Practice Location Address Fax Number:
478-745-9321
Provider Enumeration Date:
06/03/2006

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: 207RH0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00697716A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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