Provider Demographics
NPI:1720684889
Name:PURE WATER RECOVERY AND SOBER LIVING, LLC
Entity Type:Organization
Organization Name:PURE WATER RECOVERY AND SOBER LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-212-5615
Mailing Address - Street 1:15385 W FILLMORE ST UNIT 210
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-4187
Mailing Address - Country:US
Mailing Address - Phone:248-212-5615
Mailing Address - Fax:
Practice Address - Street 1:15385 W FILLMORE ST UNIT 210
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-4187
Practice Address - Country:US
Practice Address - Phone:248-212-5615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-04
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health