MEDICARE: PRUITTHEALTH - ESTILL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	NCF922	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174504203
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRUITTHEALTH - ESTILL, LLC

Provider Business Mailing Address
First Line	:	1626 JEURGENS CT
Second Line	:
City	:	NORCROSS
State	:	GA
Zip	:	30093-2219
Country	:	US
Telephone Number	:	770-279-6200
Fax Number	:

Provider Business Practice Location Address
First Line	:	252 LIBERTY STREET SOUTH
Second Line	:
City	:	ESTILL
State	:	SC
Zip	:	29918-3311
Country	:	US
Telephone Number	:	803-625-3852
Fax Number	:	803-625-2441

Authorized Official
Title or Position	:	CHAIRMAN/CEO OF MGR
Name	:	MR. NEIL LITTLE PRUITT JR.
Credential	:
Telephone Number	:	770-279-6200

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	06/30/2014

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