MEDICARE: PRUITTHEALTH - MARIETTA, 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	1-033-1793	GA

General Provider Information

NPI Number	:	1366789505
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRUITTHEALTH - MARIETTA, 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	:

Provider Business Practice Location Address
First Line	:	50 SAINE DR SW
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30008-3824
Country	:	US
Telephone Number	:	770-429-8600
Fax Number	:

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

Provider Enumeration Date	:	01/08/2013
Last Update Date	:	06/27/2014

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