Healthcare Provider Details

I. General information

NPI: 1396212684
Provider Name (Legal Business Name): PURE IV HEALTH & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 10/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MILITARY TRL STE 110
JUPITER FL
33458-4811
US

IV. Provider business mailing address

17977 KEYLIME BLVD
LOXAHATCHEE FL
33470
US

V. Phone/Fax

Practice location:
  • Phone: 561-774-3443
  • Fax: 561-630-6011
Mailing address:
  • Phone: 561-774-3443
  • Fax: 561-630-6011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SKYLAR S MILORD
Title or Position: CEO
Credential:
Phone: 561-774-3443