MEDICARE: PRUITTHEALTH - PEAKE, LLC

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	314000000X	Skilled Nursing Facility	1-011-1095	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093762510
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRUITTHEALTH - PEAKE, LLC

Provider Business Mailing Address
First Line	:	1626 JEURGENS CT
Second Line	:	LEGAL DEPT
City	:	NORCROSS
State	:	GA
Zip	:	30093-2219
Country	:	US
Telephone Number	:	770-279-6200
Fax Number	:

Provider Business Practice Location Address
First Line	:	6190 PEAKE RD
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31220-3956
Country	:	US
Telephone Number	:	478-471-7474
Fax Number	:

Authorized Official
Title or Position	:	CHAIRMAN AND CEO OF MANAGER
Name	:	NEIL L PRUITT JR.
Credential	:
Telephone Number	:	770-279-6200

Provider Enumeration Date	:	05/29/2006
Last Update Date	:	04/05/2021

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