Provider Demographics
NPI:1710643382
Name:PUR WELLNESS AND AESTHETICS
Entity Type:Organization
Organization Name:PUR WELLNESS AND AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:REBECCA
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:702-493-5720
Mailing Address - Street 1:529 GEORGE HOPPER RD.
Mailing Address - Street 2:SUITE A
Mailing Address - City:MIDLOTHAIN
Mailing Address - State:TX
Mailing Address - Zip Code:76065
Mailing Address - Country:US
Mailing Address - Phone:469-231-4596
Mailing Address - Fax:
Practice Address - Street 1:529 GEORGE HOPPER RD.
Practice Address - Street 2:SUITE A
Practice Address - City:MIDLOTHAIN
Practice Address - State:TX
Practice Address - Zip Code:76065
Practice Address - Country:US
Practice Address - Phone:469-231-4596
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty