Provider Demographics
NPI:1528680915
Name:PURE INTEGRATIVE WELLNESS AND HYDRATION LLC
Entity type:Organization
Organization Name:PURE INTEGRATIVE WELLNESS AND HYDRATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:GABRIELLE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-490-1723
Mailing Address - Street 1:2703 UNIVERSITY BLVD E STE B
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35404-3226
Mailing Address - Country:US
Mailing Address - Phone:205-248-7064
Mailing Address - Fax:888-501-7784
Practice Address - Street 1:2703 UNIVERSITY BLVD E STE B
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-3226
Practice Address - Country:US
Practice Address - Phone:205-248-7064
Practice Address - Fax:205-523-7158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-08
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty