=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114473931
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PURE PATH RECOVERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2016
-----------------------------------------------------
Last Update Date | 08/31/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 51 SORBONNE ST
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92683-8916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-375-0070
-----------------------------------------------------
Fax | 949-429-7193
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 216 TECHNOLOGY DR STE#A
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-2407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-375-0070
-----------------------------------------------------
Fax | 949-429-7193
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CFO
-----------------------------------------------------
Name | AARON JENNINGS
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 949-375-0070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 300663AP
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------