MEDICARE: TERA PRUITT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1073976007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERA PRUITT

Provider Business Mailing Address
First Line	:	6191 CROOKED CREEK DR
Second Line	:
City	:	REX
State	:	GA
Zip	:	30273-5008
Country	:	US
Telephone Number	:	404-574-3091
Fax Number	:

Provider Business Practice Location Address
First Line	:	6191 CROOKED CREEK DR
Second Line	:
City	:	REX
State	:	GA
Zip	:	30273-5008
Country	:	US
Telephone Number	:	404-574-3091
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2016
Last Update Date	:	03/29/2016

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Directions to “ TERA PRUITT ” Practice Location

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