Basic Information
| Provider Information | |||||||||
| NPI: | 1376603191 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PUEBLO BONE DENSITY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4010 JERRY MURPHY RD | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810011045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195462229 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4010 JERRY MURPHY RD | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810011045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195462229 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROUKEMA | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7195462229 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 01281013 | 05 | CO | MEDICAID |