Healthcare Provider Details

I. General information

NPI: 1720684889
Provider Name (Legal Business Name): PURE WATER RECOVERY AND SOBER LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2020
Last Update Date: 01/18/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15385 W FILLMORE ST UNIT 210
GOODYEAR AZ
85338-4187
US

IV. Provider business mailing address

15385 W FILLMORE ST UNIT 210
GOODYEAR AZ
85338-4187
US

V. Phone/Fax

Practice location:
  • Phone: 248-212-5615
  • Fax:
Mailing address:
  • Phone: 248-212-5615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: BRIDGET MILLER
Title or Position: OWNER
Credential:
Phone: 248-212-5615