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General NPI Number Information
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NPI Number | 1346786696
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Entity Type | Organization
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Legal Business Name | PURA VIDA RECOVERY SERVICES, LLC
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Dates
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Enumeration Date | 01/10/2017
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Last Update Date | 11/17/2020
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Provider Practice Location Address
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Address Line | 130 STONY POINT RD
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City | SANTA ROSA
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State | CA
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Zip | 95401-4120
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Country | US
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Telephone | 707-338-5927
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Fax |
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Provider Business Mailing Address
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Address Line | 130 STONY POINT RD STE J
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City | SANTA ROSA
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State | CA
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Zip | 95401-4120
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Country | US
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Telephone | 707-338-5927
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Fax |
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Authorized Official
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Title or Position | CAO
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Name | BEN A PAHLAVAN
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Credential |
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Telephone | 707-338-5927
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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