Healthcare Provider Details

I. General information

NPI: 1346095395
Provider Name (Legal Business Name): PUR-PUS SUPPORTED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2024
Last Update Date: 04/23/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 E MAIN ST
COLUMBUS OH
43213-2441
US

IV. Provider business mailing address

5150 E MAIN ST LOWR LEVEL
COLUMBUS OH
43213-2441
US

V. Phone/Fax

Practice location:
  • Phone: 614-671-1868
  • Fax:
Mailing address:
  • Phone: 614-671-1868
  • Fax: 614-604-8276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VIII. Authorized Official

Name: TOMIKA GORTDON
Title or Position: MANAGING MEMBER
Credential:
Phone: 614-946-5504