Provider Demographics
NPI:1275250433
Name:PURE LIFE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:PURE LIFE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:YENISLEYDIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PADRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-269-8767
Mailing Address - Street 1:1306 SE 46TH LN STE 3
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-8647
Mailing Address - Country:US
Mailing Address - Phone:239-269-8767
Mailing Address - Fax:
Practice Address - Street 1:1306 SE 46TH LN STE 3
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-8647
Practice Address - Country:US
Practice Address - Phone:239-269-8767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-27
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty