Healthcare Provider Details

I. General information

NPI: 1861321093
Provider Name (Legal Business Name): PURELINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 LINCOLN ST
WORCESTER MA
01605-2429
US

IV. Provider business mailing address

121 LINCOLN ST
WORCESTER MA
01605-2429
US

V. Phone/Fax

Practice location:
  • Phone: 774-625-3953
  • Fax:
Mailing address:
  • Phone: 774-625-3953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: IVORY FILMORE
Title or Position: CEO
Credential: PHLEBOTOMIST
Phone: 774-622-1624