1922759174 NPI number — PURE LIFE CLINIC

Table of content: (NPI 1922759174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922759174 NPI number — PURE LIFE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PURE LIFE CLINIC
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:
JASON AND MELANIE BROWN PC
Provider Other Organization Name Type Code:
5
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:
1922759174
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
118 N KILLINGSWORTH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97217-2435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-288-4454
Provider Business Mailing Address Fax Number:
503-288-1783

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
67195 E HIGHWAY 26
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WELCHES
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97067-9610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-288-4454
Provider Business Practice Location Address Fax Number:
503-288-1783
Provider Enumeration Date:
01/10/2022

Additional Information

Authorized Official

Authorized Official Last Name:
GOSTEVSKYH
Authorized Official First Name:
HIONIA
Authorized Official Middle Name:
HINA
Authorized Official Title or Position:
BILLER
Authorized Official Telephone Number:
503-288-4454

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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