=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356097075
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. TERRY M PURYEAR
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2022
-----------------------------------------------------
Last Update Date | 02/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2771 PALOMA SENDA
-----------------------------------------------------
City | BULLHEAD CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86442-7982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-577-7173
-----------------------------------------------------
Fax | 928-219-5371
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2771 PALOMA SENDA
-----------------------------------------------------
City | BULLHEAD CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86442-7982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-577-7173
-----------------------------------------------------
Fax | 928-219-5371
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 342000000X
-----------------------------------------------------
Taxonomy Name | Transportation Network Company
-----------------------------------------------------
License Number | 23147898
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------