Provider Demographics
NPI:1194439430
Name:PURA VIDA RECOVERY SERVICES, LLC
Entity type:Organization
Organization Name:PURA VIDA RECOVERY SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CAO
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:PAHLAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-879-8432
Mailing Address - Street 1:130 STONY POINT RD STE J
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4120
Mailing Address - Country:US
Mailing Address - Phone:707-879-8432
Mailing Address - Fax:844-426-0134
Practice Address - Street 1:5761 MOUNTAIN HAWK DR STE 201
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-4454
Practice Address - Country:US
Practice Address - Phone:707-879-8432
Practice Address - Fax:844-426-0134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-11
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA490041BPOtherCA DHCS