Provider Demographics
NPI:1912279407
Name:PURE LEGACY, LLC
Entity Type:Organization
Organization Name:PURE LEGACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:TASHA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:806-790-4951
Mailing Address - Street 1:PO BOX 276
Mailing Address - Street 2:
Mailing Address - City:FLOYDADA
Mailing Address - State:TX
Mailing Address - Zip Code:79235-0276
Mailing Address - Country:US
Mailing Address - Phone:806-983-3119
Mailing Address - Fax:
Practice Address - Street 1:107 W CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:FLOYDADA
Practice Address - State:TX
Practice Address - Zip Code:79235-2724
Practice Address - Country:US
Practice Address - Phone:806-983-3119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-31
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11851111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty