Provider Demographics
NPI:1346786696
Name:PURA VIDA RECOVERY SERVICES, LLC
Entity Type:Organization
Organization Name:PURA VIDA RECOVERY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CAO
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:PAHLAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-338-5927
Mailing Address - Street 1:130 STONY POINT RD STE J
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4120
Mailing Address - Country:US
Mailing Address - Phone:707-338-5927
Mailing Address - Fax:
Practice Address - Street 1:130 STONY POINT RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4120
Practice Address - Country:US
Practice Address - Phone:707-338-5927
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-10
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty