Basic Information
| Provider Information | |||||||||
| NPI: | 1821064353 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PUEBLO PEDIATRICS LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2152 S VINEYARD | ||||||||
| Address2: | SUITE 129 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852106871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807320044 | ||||||||
| FaxNumber: | 4807329333 | ||||||||
| Practice Location | |||||||||
| Address1: | 2152 S VINEYARD | ||||||||
| Address2: | SUITE 129 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852106871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807320044 | ||||||||
| FaxNumber: | 4807329333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 12/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | CHILES | ||||||||
| AuthorizedOfficialFirstName: | MARGARET | ||||||||
| AuthorizedOfficialMiddleName: | JANE | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4807320044 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | R.N. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.