MEDICARE: PURE LIFE LLC

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	251S00000X	Community/Behavioral Health Agency	NV20181591545	NV

General Provider Information

NPI Number	:	1790265544
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PURE LIFE LLC

Provider Business Mailing Address
First Line	:	2513 BRAVE HEART AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-0685
Country	:	US
Telephone Number	:	951-667-5754
Fax Number	:

Provider Business Practice Location Address
First Line	:	2513 BRAVE HEART AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-0685
Country	:	US
Telephone Number	:	951-667-5754
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KARLONDRA WILLIAMS
Credential	:
Telephone Number	:	773-701-3956

Provider Enumeration Date	:	08/20/2018
Last Update Date	:	08/20/2018

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