Healthcare Provider Details

I. General information

NPI: 1366467904
Provider Name (Legal Business Name): PURI ORTHOPEDIC CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 02/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12830 HESPERIA ROAD, SUITE A
VICTORVILLE CA
92395-7788
US

IV. Provider business mailing address

12830 HESPERIA ROAD, SUITE A
VICTORVILLE CA
92395-7788
US

V. Phone/Fax

Practice location:
  • Phone: 760-243-7715
  • Fax: 760-243-5442
Mailing address:
  • Phone: 760-243-7715
  • Fax: 760-243-5442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: LEATA MOORE
Title or Position: BILLING MANAGER
Credential:
Phone: 760-243-0464