Healthcare Provider Details

I. General information

NPI: 1912274408
Provider Name (Legal Business Name): PURITY INTEGRATIVE HEALTH & WELLNESS CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15118 MAIN ST SUITE 500
MILL CREEK WA
98012-1653
US

IV. Provider business mailing address

2980 N BEVERLY GLEN CIR SUITE 100
LOS ANGELES CA
90077-1726
US

V. Phone/Fax

Practice location:
  • Phone: 425-337-7029
  • Fax:
Mailing address:
  • Phone: 310-943-4180
  • Fax: 888-431-8819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberNT 60255395
License Number StateWA

VIII. Authorized Official

Name: CHELSEA R. GORDON
Title or Position: OWNER
Credential: ND
Phone: 425-337-7029