Healthcare Provider Details

I. General information

NPI: 1912440645
Provider Name (Legal Business Name): PURE LIFE RECOVERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2016
Last Update Date: 04/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19915 FORTUNA DEL ESTE
ESCONDIDO CA
92029-5917
US

IV. Provider business mailing address

901 CALLE AMANECER SUITE 255
SAN CLEMENTE CA
92673-6278
US

V. Phone/Fax

Practice location:
  • Phone: 760-290-4749
  • Fax:
Mailing address:
  • Phone: 949-629-3936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number370174AP
License Number StateCA

VIII. Authorized Official

Name: MR. BEN BEAUCHAINE
Title or Position: CEO
Credential:
Phone: 714-417-7628