Provider Demographics
NPI:1114473931
Name:PURE PATH RECOVERY
Entity Type:Organization
Organization Name:PURE PATH RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CFO
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:949-375-0070
Mailing Address - Street 1:216 TECHNOLOGY DR
Mailing Address - Street 2:STE#A
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2407
Mailing Address - Country:US
Mailing Address - Phone:949-375-0070
Mailing Address - Fax:949-429-7193
Practice Address - Street 1:51 SORBONNE ST
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-8916
Practice Address - Country:US
Practice Address - Phone:949-375-0070
Practice Address - Fax:949-429-7193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300663AP261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA300663APOtherLICENSE