=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245521525
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRISTINE VENTURES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2011
-----------------------------------------------------
Last Update Date | 04/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1965 CAPITAL CIR NE
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32308-8401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-445-4365
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1744 RODEO DR
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32311-8548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-933-5242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. GABRIEL OKEOMA OTUONYE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-933-5242
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | L11000044712
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------