Healthcare Provider Details

I. General information

NPI: 1174570600
Provider Name (Legal Business Name): PRUITTHEALTH - TOCCOA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2006
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 FALLS RD
TOCCOA GA
30577-1607
US

IV. Provider business mailing address

1626 JEURGENS CT
NORCROSS GA
30093-2219
US

V. Phone/Fax

Practice location:
  • Phone: 706-886-8491
  • 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 Number1-127-371
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00143305A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

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