Healthcare Provider Details

I. General information

NPI: 1497403646
Provider Name (Legal Business Name): PURE HEALTHCARE OF SOUTH DAKOTA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2022
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 1ST AVE SW STE A
WATERTOWN SD
57201-3507
US

IV. Provider business mailing address

4179 S RIVERBOAT RD STE 220
TAYLORSVILLE UT
84123-2986
US

V. Phone/Fax

Practice location:
  • Phone: 801-590-9267
  • Fax:
Mailing address:
  • Phone: 801-590-9267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA T TANDY
Title or Position: DIRECTOR
Credential:
Phone: 801-590-9267