Healthcare Provider Details

I. General information

NPI: 1811324825
Provider Name (Legal Business Name): PURE PEDIATRIC THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2013
Last Update Date: 04/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24422 AVENIDA DE LA CARLOTA SUITE 100
LAGUNA HILLS CA
92653-3636
US

IV. Provider business mailing address

5 SUMMIT
IRVINE CA
92603-3625
US

V. Phone/Fax

Practice location:
  • Phone: 310-940-8212
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MS. ELIZABETH KOREN
Title or Position: OWNER
Credential:
Phone: 310-940-8212