Provider Demographics
NPI:1003323767
Name:PURE LIFE PTG
Entity Type:Organization
Organization Name:PURE LIFE PTG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-664-3741
Mailing Address - Street 1:14218 S CANYON VINE CV
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-5631
Mailing Address - Country:US
Mailing Address - Phone:801-878-9597
Mailing Address - Fax:
Practice Address - Street 1:7390 S CREEK RD STE 202
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-6123
Practice Address - Country:US
Practice Address - Phone:801-893-2550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty