Healthcare Provider Details

I. General information

NPI: 1730136599
Provider Name (Legal Business Name): PRUITTHEALTH - BLUE RIDGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 04/07/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 OUIDA ST
BLUE RIDGE GA
30513-4627
US

IV. Provider business mailing address

1626 JEURGENS CT LEGAL DEPT
NORCROSS GA
30093-2219
US

V. Phone/Fax

Practice location:
  • Phone: 706-632-2271
  • Fax: 706-632-7633
Mailing address:
  • Phone: 770-279-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1-055-1198
License Number StateGA

VIII. Authorized Official

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