Provider Demographics
NPI:1750158036
Name:PURA PRIMARY CARE
Entity type:Organization
Organization Name:PURA PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FALLON
Authorized Official - Middle Name:R
Authorized Official - Last Name:DAMICO
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:602-670-5413
Mailing Address - Street 1:9305 W THOMAS RD STE 285
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-3365
Mailing Address - Country:US
Mailing Address - Phone:602-677-3801
Mailing Address - Fax:
Practice Address - Street 1:9305 W THOMAS RD STE 285
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3365
Practice Address - Country:US
Practice Address - Phone:602-677-3801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PURA PRIMARY CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-12-07
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty