Provider Demographics
NPI:1578291092
Name:PURE LIFE THERAPY, LLC
Entity Type:Organization
Organization Name:PURE LIFE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNLAVY
Authorized Official - Suffix:
Authorized Official - Credentials:PLMHP
Authorized Official - Phone:402-543-3392
Mailing Address - Street 1:11580 W DODGE RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-2537
Mailing Address - Country:US
Mailing Address - Phone:402-238-1431
Mailing Address - Fax:
Practice Address - Street 1:11580 W DODGE RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-2537
Practice Address - Country:US
Practice Address - Phone:402-238-1431
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)