Provider Demographics
NPI:1952032328
Name:AZ PURE WELLNESS LLC
Entity Type:Organization
Organization Name:AZ PURE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FAJARDO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:602-825-3925
Mailing Address - Street 1:7865 W BELL RD # 1056
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-3803
Mailing Address - Country:US
Mailing Address - Phone:602-825-3925
Mailing Address - Fax:
Practice Address - Street 1:7865 W BELL RD # 1056
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-3803
Practice Address - Country:US
Practice Address - Phone:602-825-3925
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty