Healthcare Provider Details

I. General information

NPI: 1154184018
Provider Name (Legal Business Name): PURE PULSE HEALTH PHYSICIAN ASSISTANT, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2024
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 MAGNOLIA AVE STE 102
CORONA CA
92879-3124
US

IV. Provider business mailing address

802 MAGNOLIA AVE STE 102
CORONA CA
92879-3124
US

V. Phone/Fax

Practice location:
  • Phone: 714-455-9831
  • Fax:
Mailing address:
  • Phone: 714-455-9831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. DIPALI P RADIA
Title or Position: CEO
Credential: PA-C
Phone: 714-553-5100