Healthcare Provider Details

I. General information

NPI: 1275495764
Provider Name (Legal Business Name): ADAM CLAY PRUITT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

838 HIDDEN ESTATES LN
SAINT ANTHONY ID
83445-5519
US

IV. Provider business mailing address

838 HIDDEN ESTATES LN
SAINT ANTHONY ID
83445-5519
US

V. Phone/Fax

Practice location:
  • Phone: 901-494-2969
  • Fax:
Mailing address:
  • Phone: 901-494-2969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: