Basic Information
| Provider Information | |||||||||
| NPI: | 1396098828 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUEBLO COMMUNITY HEALTH CENTER | ||||||||
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| OtherOrganizationName: | #70 SBWC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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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: | 1050 35TH LN | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810069426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195438711 | ||||||||
| FaxNumber: | 7195435340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2012 | ||||||||
| LastUpdateDate: | 11/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
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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 | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.