Provider Demographics
NPI:1104788298
Name:PURELIFE MEDICAL SUPPLY LLC
Entity type:Organization
Organization Name:PURELIFE MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:INFANT
Authorized Official - Middle Name:
Authorized Official - Last Name:CORONADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:945-346-9150
Mailing Address - Street 1:5900 BALCONES DR # 9235
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-4257
Mailing Address - Country:US
Mailing Address - Phone:469-758-0055
Mailing Address - Fax:
Practice Address - Street 1:5900 BALCONES DR # 9235
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-4257
Practice Address - Country:US
Practice Address - Phone:469-758-0055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-11-26
Last Update Date:2025-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies