Provider Demographics
NPI:1487431359
Name:THE PURE LIFE CENTER, LLC
Entity type:Organization
Organization Name:THE PURE LIFE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:LISTER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:970-987-2583
Mailing Address - Street 1:4275 W 107TH DR
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80031-1994
Mailing Address - Country:US
Mailing Address - Phone:970-987-2583
Mailing Address - Fax:
Practice Address - Street 1:2503 WALNUT ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5748
Practice Address - Country:US
Practice Address - Phone:970-987-2583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility