Healthcare Provider Details

I. General information

NPI: 1003302027
Provider Name (Legal Business Name): PRUITTHEALTH - PANAMA CITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 11/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3212 JENKS AVE
PANAMA CITY FL
32405-4224
US

IV. Provider business mailing address

1626 JEURGENS CT
NORCROSS GA
30093-2219
US

V. Phone/Fax

Practice location:
  • Phone: 850-771-1521
  • Fax: 850-771-1522
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: NEIL L. PRUITT JR.
Title or Position: CHAIRMAN AND CEO OF MANAGER
Credential:
Phone: 770-279-6200