Provider Demographics
NPI:1922759174
Name:PURE LIFE CLINIC
Entity Type:Organization
Organization Name:PURE LIFE CLINIC
Other - Org Name:JASON AND MELANIE BROWN PC
Other - Org Type:Other Name
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:HIONIA
Authorized Official - Middle Name:HINA
Authorized Official - Last Name:GOSTEVSKYH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-288-4454
Mailing Address - Street 1:118 N KILLINGSWORTH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-2435
Mailing Address - Country:US
Mailing Address - Phone:503-288-4454
Mailing Address - Fax:503-288-1783
Practice Address - Street 1:67195 E HIGHWAY 26
Practice Address - Street 2:
Practice Address - City:WELCHES
Practice Address - State:OR
Practice Address - Zip Code:97067-9610
Practice Address - Country:US
Practice Address - Phone:503-288-4454
Practice Address - Fax:503-288-1783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-10
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty