Provider Demographics
NPI:1447536057
Name:JESSIE R. PRUITT DBA SLEEP 2 GO
Entity type:Organization
Organization Name:JESSIE R. PRUITT DBA SLEEP 2 GO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:RAYLENE
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:
Authorized Official - Credentials:CRT
Authorized Official - Phone:806-322-0941
Mailing Address - Street 1:6652 CANYON DR STE 3
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-7013
Mailing Address - Country:US
Mailing Address - Phone:806-322-0941
Mailing Address - Fax:
Practice Address - Street 1:6652 CANYON DR STE 3
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-7013
Practice Address - Country:US
Practice Address - Phone:806-322-0941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1000557332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1000557OtherTEXAS DEPARTMENT OF HEALTH DEVICE DISTRIBUTOR LICENSE