Healthcare Provider Details

I. General information

NPI: 1790239903
Provider Name (Legal Business Name): PURE ONE WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2016
Last Update Date: 08/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 S FARVIEW AVE STE. #C
PARAMUS NJ
07652-2501
US

IV. Provider business mailing address

107 S FARVIEW AVE STE. #C
PARAMUS NJ
07652-2501
US

V. Phone/Fax

Practice location:
  • Phone: 201-994-9782
  • Fax:
Mailing address:
  • Phone: 201-994-9782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER CARROLL
Title or Position: OFFICE REP
Credential:
Phone: 352-942-1204