Provider Demographics
NPI:1346095395
Name:PUR-PUS SUPPORTED LIVING
Entity Type:Organization
Organization Name:PUR-PUS SUPPORTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TOMIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:GORTDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-946-5504
Mailing Address - Street 1:5150 E MAIN ST LOWR LEVEL
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-2441
Mailing Address - Country:US
Mailing Address - Phone:614-671-1868
Mailing Address - Fax:614-604-8276
Practice Address - Street 1:5150 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-2441
Practice Address - Country:US
Practice Address - Phone:614-671-1868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances