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General NPI Number Information
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NPI Number | 1285094011
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Entity Type | Organization
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Legal Business Name | PURE SPA & WELLNESS
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Dates
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Enumeration Date | 03/07/2016
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Last Update Date | 03/07/2016
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Provider Practice Location Address
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Address Line | 279 S PURCELL BLVD STE 100
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City | PUEBLO WEST
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State | CO
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Zip | 81007-5083
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Country | US
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Telephone | 719-582-1432
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Fax |
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Provider Business Mailing Address
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Address Line | 279 S PURCELL BLVD STE 100
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City | PUEBLO WEST
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State | CO
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Zip | 81007-5083
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Country | US
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Telephone | 719-582-1432
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Fax |
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Authorized Official
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Title or Position | MEDICAL MASSAGE THERAPIST
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Name | MR. TAD DORSEY CHILDERS
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Credential | LCMT
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Telephone | 719-582-1432
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT.0006794
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License Number State | CO
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