Healthcare Provider Details

I. General information

NPI: 1710010715
Provider Name (Legal Business Name): PRUITTHEALTH - BLUE RIDGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 06/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 OUIDA STREET
BLUE RIDGE GA
30513
US

IV. Provider business mailing address

1626 JEURGENS CT
NORCROSS GA
30093-2219
US

V. Phone/Fax

Practice location:
  • Phone: 706-258-2819
  • Fax:
Mailing address:
  • Phone: 770-279-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

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