Provider Demographics
NPI:1912440645
Name:PURE LIFE RECOVERY, LLC
Entity Type:Organization
Organization Name:PURE LIFE RECOVERY, LLC
Other - Org Name:SHORELINE RANCH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAUCHAINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-417-7628
Mailing Address - Street 1:901 CALLE AMANECER
Mailing Address - Street 2:SUITE 255
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-6278
Mailing Address - Country:US
Mailing Address - Phone:949-629-3936
Mailing Address - Fax:
Practice Address - Street 1:19915 FORTUNA DEL ESTE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92029-5917
Practice Address - Country:US
Practice Address - Phone:760-290-4749
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-29
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA370174AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA370174APOtherSTATE LICENSE - DHCS