Provider Demographics
NPI:1962094219
Name:PURE PERFORMANCE REHAB
Entity type:Organization
Organization Name:PURE PERFORMANCE REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:MALLON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:541-490-4450
Mailing Address - Street 1:235 E WHITLOCK AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-3224
Mailing Address - Country:US
Mailing Address - Phone:541-490-4450
Mailing Address - Fax:
Practice Address - Street 1:2295 S 2000 E UNIT C
Practice Address - Street 2:
Practice Address - City:MILLCREEK
Practice Address - State:UT
Practice Address - Zip Code:84106-4138
Practice Address - Country:US
Practice Address - Phone:541-490-4450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:12066486-0162
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy