Provider Demographics
NPI:1063178713
Name:PURVIS, LAURA (LMT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:PURVIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 W COMMONWEALTH AVE # 280
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-3019
Mailing Address - Country:US
Mailing Address - Phone:909-325-0502
Mailing Address - Fax:
Practice Address - Street 1:2100 W COMMONWEALTH AVE # 280
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-3019
Practice Address - Country:US
Practice Address - Phone:909-325-0502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79699225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist