Provider Demographics
NPI:1003521485
Name:PURE LIFE HEALTH AND WELLNESS LLC
Entity Type:Organization
Organization Name:PURE LIFE HEALTH AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:AJ
Authorized Official - Middle Name:
Authorized Official - Last Name:YERGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-986-9369
Mailing Address - Street 1:617 E RIVERSIDE DR STE 104
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-8720
Mailing Address - Country:US
Mailing Address - Phone:801-638-7826
Mailing Address - Fax:
Practice Address - Street 1:617 E RIVERSIDE DR STE 104
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-8720
Practice Address - Country:US
Practice Address - Phone:801-638-7826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty