=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538601919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PURA VIDA PHC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2016
-----------------------------------------------------
Last Update Date | 11/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 108 N JACKSON RD STE 13
-----------------------------------------------------
City | EDINBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78541-3692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-720-0216
-----------------------------------------------------
Fax | 866-781-3114
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 108 N JACKSON RD STE 13
-----------------------------------------------------
City | EDINBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78541-3692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-720-0216
-----------------------------------------------------
Fax | 866-781-3114
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER/OWNER
-----------------------------------------------------
Name | MR. ARMANDO M GUERRA
-----------------------------------------------------
Credential | J.D.
-----------------------------------------------------
Telephone | 956-739-1920
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------