Provider Demographics
NPI:1497345953
Name:PURE LIFE ADVENTURE, LLC
Entity Type:Organization
Organization Name:PURE LIFE ADVENTURE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-232-5568
Mailing Address - Street 1:4685 S HIGHLAND DR STE 224
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-5298
Mailing Address - Country:US
Mailing Address - Phone:801-232-5568
Mailing Address - Fax:
Practice Address - Street 1:600 METROS ESTE DE LA ESCUELA DE LAS TUMBAS
Practice Address - Street 2:
Practice Address - City:LAS TUMBAS
Practice Address - State:COSTA RICA
Practice Address - Zip Code:10110
Practice Address - Country:CR
Practice Address - Phone:801-232-5568
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children