| Pure Life Clinic Llc | |
|
4725 Statesmen Dr Ste B Indianapolis IN 46250-5645 | |
| (480) 566-9755 | |
| Not Available |
| Full Name | Pure Life Clinic Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 4725 Statesmen Dr Ste B, Indianapolis, Indiana |
| Authorized Official Name and Position | Shawn Vigneau (SOLE MBR) |
| Authorized Official Contact | 4802909899 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Pure Life Clinic Llc 4725 Statesmen Dr Ste B Indianapolis IN 46250-5645 Ph: (480) 566-9755 | Pure Life Clinic Llc 4725 Statesmen Dr Ste B Indianapolis IN 46250-5645 Ph: (480) 566-9755 |
| NPI Number | 1932677291 |
|---|---|
| Provider Enumeration Date | 11/05/2018 |
| Last Update Date | 11/05/2018 |
| Medicare PECOS PAC ID | 8921403049 |
|---|---|
| Medicare Enrollment ID | O20210826002895 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1932677291 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM1300X | Clinic/center - Multi-specialty | (* (Not Available)) | Primary |
| Provider Name | Rachel L Boggus |
|---|---|
| Provider Type | Practitioner - Anesthesiology |
| Provider Identifiers | NPI Number: 1427215987 PECOS PAC ID: 3375707847 Enrollment ID: I20120613000192 |
| Provider Name | Shawn Vigneau |
|---|---|
| Provider Type | Practitioner - Chiropractic |
| Provider Identifiers | NPI Number: 1912165275 PECOS PAC ID: 3072768241 Enrollment ID: I20210826002986 |
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