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General NPI Number Information
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NPI Number | 1891230454
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Entity Type | Organization
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Legal Business Name | PURE HEALTHY BACK
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Dates
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Enumeration Date | 01/05/2017
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Last Update Date | 01/05/2017
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Provider Practice Location Address
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Address Line | 1500 W BIG BEAVER RD STE 150
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City | TROY
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State | MI
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Zip | 48084-3552
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Country | US
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Telephone | 248-649-2323
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Fax |
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Provider Business Mailing Address
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Address Line | 1500 W BIG BEAVER RD STE 150
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City | TROY
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State | MI
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Zip | 48084-3552
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | SANDRA AZAR
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Credential |
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Telephone | 248-649-2323
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 5501009288
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License Number State | MI
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