Provider Demographics
NPI:1992556773
Name:PURE LIVING RECOVERY AND REHABILITION CENTER
Entity type:Organization
Organization Name:PURE LIVING RECOVERY AND REHABILITION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:DEMARIAL
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-701-0405
Mailing Address - Street 1:5601 STATE ST
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62203-1346
Mailing Address - Country:US
Mailing Address - Phone:314-701-0405
Mailing Address - Fax:
Practice Address - Street 1:5601 STATE ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62203-1346
Practice Address - Country:US
Practice Address - Phone:314-701-0405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PURE LIVING RECOVERY AND REHABILITATION CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-03-29
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health