Provider Demographics
NPI:1467945865
Name:PURE G KIDS, LLC
Entity Type:Organization
Organization Name:PURE G KIDS, LLC
Other - Org Name:PURE G KIDS WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:432-701-0093
Mailing Address - Street 1:21175 TOMBALL PKWY STE 379
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-1655
Mailing Address - Country:US
Mailing Address - Phone:432-701-0093
Mailing Address - Fax:
Practice Address - Street 1:21175 TOMBALL PKWY STE 379
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070
Practice Address - Country:US
Practice Address - Phone:432-701-0093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-11
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRO366208000000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty