Healthcare Provider Details

I. General information

NPI: 1063280568
Provider Name (Legal Business Name): PUEBLO MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2023
Last Update Date: 12/13/2023
Certification Date: 12/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 S 12TH AVE
TUCSON AZ
85713-5914
US

IV. Provider business mailing address

3535 S 12TH AVE
TUCSON AZ
85713-5914
US

V. Phone/Fax

Practice location:
  • Phone: 520-622-8384
  • Fax:
Mailing address:
  • Phone: 520-622-8384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN QUENTIN HARRIS
Title or Position: PROVIDER
Credential: DO
Phone: 520-622-8384