1619115045 NPI number — PURE HEALTHCARE LLC

Table of content: (NPI 1619115045)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619115045 NPI number — PURE HEALTHCARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PURE HEALTHCARE 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:
INNOVATIVE CARE SOLUTIONS LLC
Provider Other Organization Name Type Code:
4
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:
1619115045
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2200 MIAMI VALLEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45459-4783
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-668-7873
Provider Business Mailing Address Fax Number:
888-965-4549

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 MIAMI VALLEY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45459-4783
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-668-7873
Provider Business Practice Location Address Fax Number:
888-965-4549
Provider Enumeration Date:
01/22/2009

Additional Information

Authorized Official

Authorized Official Last Name:
KEMPER
Authorized Official First Name:
AMY
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF FINANCE AND ANALYTICS
Authorized Official Telephone Number:
937-479-0377

Provider Taxonomy Codes

  • Taxonomy code: 207QH0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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