Provider Demographics
NPI:1588947204
Name:PURE PEDIATRIC THERAPY
Entity type:Organization
Organization Name:PURE PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDZIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-916-1654
Mailing Address - Street 1:24422 AVENIDA DE LA CARLOTA
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3636
Mailing Address - Country:US
Mailing Address - Phone:949-916-1654
Mailing Address - Fax:
Practice Address - Street 1:24422 AVENIDA DE LA CARLOTA
Practice Address - Street 2:SUITE 100
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3636
Practice Address - Country:US
Practice Address - Phone:949-916-1654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7748225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty