Healthcare Provider Details

I. General information

NPI: 1588315865
Provider Name (Legal Business Name): PURA VIDA HEALTH INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2022
Last Update Date: 07/08/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 SUGARTOWN RD
WAYNE PA
19087-3137
US

IV. Provider business mailing address

215 SUGARTOWN RD
WAYNE PA
19087-3137
US

V. Phone/Fax

Practice location:
  • Phone: 215-806-6270
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER MULHOLLAND
Title or Position: OWNER
Credential: DO
Phone: 215-806-6270