MEDICARE: PURE PRIMARY WELLNESS AND AESTHETICS, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1497588719
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PURE PRIMARY WELLNESS AND AESTHETICS, PLLC

Provider Business Mailing Address
First Line	:	215 E JEFFERSON ST
Second Line	:
City	:	MONROE
State	:	NC
Zip	:	28112-4865
Country	:	US
Telephone Number	:	704-283-8131
Fax Number	:	704-289-1954

Provider Business Practice Location Address
First Line	:	215 E JEFFERSON ST
Second Line	:
City	:	MONROE
State	:	NC
Zip	:	28112-4865
Country	:	US
Telephone Number	:	704-283-8131
Fax Number	:	704-289-1954

Authorized Official
Title or Position	:	PROVIDER
Name	:	MRS. ELIZABETH ANDERSON
Credential	:	PA
Telephone Number	:	631-235-2578

Provider Enumeration Date	:	08/22/2024
Last Update Date	:	08/22/2024

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