Healthcare Provider Details

I. General information

NPI: 1225422066
Provider Name (Legal Business Name): PURE LIFE RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CALLE SALTAMONTES
SAN CLEMENTE CA
92673-7004
US

IV. Provider business mailing address

1620 CENTRAL AVE SUITE 202
CHEYENNE WY
82001-4557
US

V. Phone/Fax

Practice location:
  • Phone: 949-393-5033
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number300308BP
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number300308BP
License Number StateCA

VIII. Authorized Official

Name: JEFFREY WILHITE
Title or Position: PRESIDENT
Credential:
Phone: 949-899-0895