Healthcare Provider Details

I. General information

NPI: 1821064353
Provider Name (Legal Business Name): PUEBLO PEDIATRICS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 12/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2152 S VINEYARD SUITE 129
MESA AZ
85210-6871
US

IV. Provider business mailing address

2152 S VINEYARD SUITE 129
MESA AZ
85210-6871
US

V. Phone/Fax

Practice location:
  • Phone: 480-732-0044
  • Fax: 480-732-9333
Mailing address:
  • Phone: 480-732-0044
  • Fax: 480-732-9333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateAZ

VIII. Authorized Official

Name: MARGARET JANE CHILES
Title or Position: ADMINISTRATOR
Credential: R.N.
Phone: 480-732-0044