Healthcare Provider Details

I. General information

NPI: 1104788298
Provider Name (Legal Business Name): PURELIFE MEDICAL SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2025
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 BALCONES DR # 9235
AUSTIN TX
78731-4257
US

IV. Provider business mailing address

5900 BALCONES DR # 9235
AUSTIN TX
78731-4257
US

V. Phone/Fax

Practice location:
  • Phone: 469-758-0055
  • Fax:
Mailing address:
  • Phone: 469-758-0055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: INFANT CORONADO
Title or Position: OWNER
Credential:
Phone: 945-346-9150