=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124815980
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PURA VIDA CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2025
-----------------------------------------------------
Last Update Date | 04/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2150 E TAHQUITZ CANYON WAY STE 5
-----------------------------------------------------
City | PALM SPRINGS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92262-6817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-836-6555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31682 VIA VENTANA
-----------------------------------------------------
City | THOUSAND PALMS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92276-3374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | JESSICA GUADALUPE LOERA SERA
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 760-641-4396
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------