=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275139958
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PURE LIFE NM INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2020
-----------------------------------------------------
Last Update Date | 12/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 CALLE MEDICO
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-4724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-467-8372
-----------------------------------------------------
Fax | 505-780-8285
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 CALLE MEDICO
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-4724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-467-8372
-----------------------------------------------------
Fax | 505-780-8285
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PA/CEO
-----------------------------------------------------
Name | MS. LORETTA TORRES
-----------------------------------------------------
Credential | PHYSICIAN ASSISTANT
-----------------------------------------------------
Telephone | 505-467-8372
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------