Healthcare Provider Details

I. General information

NPI: 1316992605
Provider Name (Legal Business Name): PRUITTHEALTH - SANTA ROSA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5530 NORTHROP ROAD
MILTON FL
32570-8701
US

IV. Provider business mailing address

1626 JEURGENS CT
NORCROSS GA
30093-2219
US

V. Phone/Fax

Practice location:
  • Phone: 850-983-8888
  • Fax: 850-983-8880
Mailing address:
  • Phone: 770-279-6200
  • Fax: 706-886-0542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF130471024
License Number StateFL

VIII. Authorized Official

Name: NEIL L. PRUITT JR.
Title or Position: CHAIRMAN & CEO OF MGR
Credential:
Phone: 770-279-6200