Healthcare Provider Details

I. General information

NPI: 1275139958
Provider Name (Legal Business Name): PURE LIFE NM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 CALLE MEDICO
SANTA FE NM
87505-4724
US

IV. Provider business mailing address

9 CALLE MEDICO
SANTA FE NM
87505-4724
US

V. Phone/Fax

Practice location:
  • Phone: 505-467-8372
  • Fax: 505-780-8285
Mailing address:
  • Phone: 505-467-8372
  • Fax: 505-780-8285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MS. LORETTA TORRES
Title or Position: PA/CEO
Credential: PHYSICIAN ASSISTANT
Phone: 505-467-8372