Healthcare Provider Details

I. General information

NPI: 1821705237
Provider Name (Legal Business Name): PRUITTHEALTH - NORTH TAMPA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2022
Last Update Date: 11/04/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18940 SUNLAKE BLVD
LUTZ FL
33558-4943
US

IV. Provider business mailing address

1626 JEURGENS CT ATTN: LEGAL DEPT
NORCROSS GA
30093
US

V. Phone/Fax

Practice location:
  • Phone: 770-296-6200
  • Fax:
Mailing address:
  • Phone: 770-279-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. NEIL L PRUITT JR.
Title or Position: CHAIRMAN AND CEO
Credential:
Phone: 770-279-6200