Provider Demographics
NPI:1275139958
Name:PURE LIFE NM INC
Entity Type:Organization
Organization Name:PURE LIFE NM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICIAN ASSISTANT
Authorized Official - Phone:505-467-8372
Mailing Address - Street 1:9 CALLE MEDICO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4724
Mailing Address - Country:US
Mailing Address - Phone:505-467-8372
Mailing Address - Fax:505-780-8285
Practice Address - Street 1:9 CALLE MEDICO
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4724
Practice Address - Country:US
Practice Address - Phone:505-467-8372
Practice Address - Fax:505-780-8285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty