Healthcare Provider Details

I. General information

NPI: 1619922986
Provider Name (Legal Business Name): PRUITTHEALTH - SHEPHERD HILLS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 07/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 PATTERSON RD
LA FAYETTE GA
30728-3330
US

IV. Provider business mailing address

1626 JEURGENS CT
NORCROSS GA
30093-2219
US

V. Phone/Fax

Practice location:
  • Phone: 706-638-4112
  • 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 Number1-146-1671
License Number StateGA

VIII. Authorized Official

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