=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003521485
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PURE LIFE HEALTH AND WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2023
-----------------------------------------------------
Last Update Date | 01/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 617 E RIVERSIDE DR STE 104
-----------------------------------------------------
City | ST GEORGE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84790-8720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-638-7826
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 617 E RIVERSIDE DR STE 104
-----------------------------------------------------
City | ST GEORGE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84790-8720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-638-7826
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMIN
-----------------------------------------------------
Name | AJ YERGENSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 435-986-9369
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------