Healthcare Provider Details

I. General information

NPI: 1104221332
Provider Name (Legal Business Name): PURO HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2014
Last Update Date: 10/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2776 PACIFIC AVE
LONG BEACH CA
90806-2613
US

IV. Provider business mailing address

14120 ALONDRA BLVD SUITE C
SANTA FE SPRINGS CA
90670-5820
US

V. Phone/Fax

Practice location:
  • Phone: 562-407-2080
  • Fax: 562-407-2082
Mailing address:
  • Phone: 562-407-2080
  • Fax: 562-407-2082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA125312
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberA125312
License Number StateCA

VIII. Authorized Official

Name: GABRIEL CHARLES WADE
Title or Position: PRESIDENT
Credential: MD
Phone: 562-407-2080