Provider Demographics
NPI:1144573080
Name:PURE DIVERGENCE
Entity Type:Organization
Organization Name:PURE DIVERGENCE
Other - Org Name:SARAH WHITEWATER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITEWATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-779-4334
Mailing Address - Street 1:PO BOX 334
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-0334
Mailing Address - Country:US
Mailing Address - Phone:405-779-4334
Mailing Address - Fax:
Practice Address - Street 1:508 CHEROKEE GATE DR
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-0334
Practice Address - Country:US
Practice Address - Phone:405-779-4334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-16
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health