1306900485 NPI number — PRUITTHEALTH HOME FIRST, INC.

Table of content: (NPI 1306900485)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306900485 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:
1306900485
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2018
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:
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:
706-549-3315
Provider Business Mailing Address Fax Number:
706-552-1455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1751 MERIWEATHER DRIVE
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
WATKINSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30677
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-549-3315
Provider Business Practice Location Address Fax Number:
706-552-1455
Provider Enumeration Date:
12/21/2006

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

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

  • Identifier: 85500800G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com