1184445140 NPI number — PURA VIDA RECOVERY SERVICES, LLC

Table of content: (NPI 1184445140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184445140 NPI number — PURA VIDA RECOVERY SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PURA VIDA RECOVERY SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184445140
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2901 CLEVELAND AVE STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95403-2788
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-879-8432
Provider Business Mailing Address Fax Number:
844-426-0134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2901 CLEVELAND AVE STE 101&103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95403-2785
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-879-8432
Provider Business Practice Location Address Fax Number:
844-426-0134
Provider Enumeration Date:
10/22/2024

Additional Information

Authorized Official

Authorized Official Last Name:
PAHLAVAN
Authorized Official First Name:
BEN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CAO
Authorized Official Telephone Number:
707-879-8432

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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