MEDICARE: PRUITTHEALTH - VIRGINIA PARK, 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

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	:	1134500754
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRUITTHEALTH - VIRGINIA PARK, LLC

Provider Business Mailing Address
First Line	:	1626 JEURGENS CT
Second Line	:
City	:	NORCROSS
State	:	GA
Zip	:	30093-2219
Country	:	US
Telephone Number	:	770-279-6200
Fax Number	:	770-931-5278

Provider Business Practice Location Address
First Line	:	1000 BRIARCLIFF RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30306-2618
Country	:	US
Telephone Number	:	404-875-6456
Fax Number	:	404-874-4606

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

Provider Enumeration Date	:	06/10/2015
Last Update Date	:	06/10/2015

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