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General NPI Number Information
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NPI Number | 1710119821
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Entity Type | Organization
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Legal Business Name | P.U.R.E. GOLF
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Dates
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Enumeration Date | 08/23/2009
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Last Update Date | 08/23/2009
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Provider Practice Location Address
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Address Line | 1727 DEER RUN DR
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City | MONTGOMERY
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State | IL
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Zip | 60538-3000
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Country | US
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Telephone | 630-362-5172
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Fax |
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Provider Business Mailing Address
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Address Line | 1727 DEER RUN DR
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City | MONTGOMERY
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State | IL
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Zip | 60538-3000
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Country | US
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Telephone | 630-362-5172
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | COREY PUYEAR
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Credential | PT
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Telephone | 630-362-5172
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 070.010664
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License Number State | IL
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