1497345953 NPI number — PURE LIFE ADVENTURE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497345953 NPI number — PURE LIFE ADVENTURE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PURE LIFE ADVENTURE, 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:
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:
1497345953
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4685 S HIGHLAND DR STE 224
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLADAY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84117-5298
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-232-5568
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 METROS ESTE DE LA ESCUELA DE LAS TUMBAS
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS TUMBAS
Provider Business Practice Location Address State Name:
COSTA RICA
Provider Business Practice Location Address Postal Code:
10110
Provider Business Practice Location Address Country Code:
CR
Provider Business Practice Location Address Telephone Number:
801-232-5568
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/19/2021

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR/OWNER
Authorized Official Telephone Number:
801-232-5568

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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