Healthcare Provider Details

I. General information

NPI: 1467945865
Provider Name (Legal Business Name): PURE G KIDS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21175 TOMBALL PKWY STE 379
HOUSTON TX
77070
US

IV. Provider business mailing address

21175 TOMBALL PKWY STE 379
HOUSTON TX
77070-1655
US

V. Phone/Fax

Practice location:
  • Phone: 432-701-0093
  • Fax:
Mailing address:
  • Phone: 432-701-0093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberRO366
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. TAMIKA BUSH
Title or Position: CEO
Credential: DO
Phone: 432-701-0093