=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245691625
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BELLA VITA HEALTHCARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2016
-----------------------------------------------------
Last Update Date | 03/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 203 S CANDY LN SUITE 6AB
-----------------------------------------------------
City | COTTONWOOD
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86326-4120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-634-0391
-----------------------------------------------------
Fax | 928-634-6145
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 203 S CANDY LN SUITE 6AB
-----------------------------------------------------
City | COTTONWOOD
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86326-4120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-634-0391
-----------------------------------------------------
Fax | 928-634-6145
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. STEPHANIE PURINTON
-----------------------------------------------------
Credential | CNM
-----------------------------------------------------
Telephone | 928-300-5360
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number | AP3450
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------