Basic Information
| Provider Information | |||||||||
| NPI: | 1013271329 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PUEBLO COMMUNITY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 E ROUTT AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810042117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195438711 | ||||||||
| FaxNumber: | 7195435340 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 COLORADO AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810042006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195438711 | ||||||||
| FaxNumber: | 7195435340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2012 | ||||||||
| LastUpdateDate: | 07/02/2012 | ||||||||
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| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | DONNALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7195438711 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | 50145 | CO | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.