Healthcare Provider Details

I. General information

NPI: 1790608776
Provider Name (Legal Business Name): PUEBLO COMMUNITY HEALTH CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CARSON AVENUE STE SPECIALTY CLINIC
LA JUNTA CO
81050
US

IV. Provider business mailing address

110 E ROUTT AVE
PUEBLO CO
81004-2117
US

V. Phone/Fax

Practice location:
  • Phone: 719-543-8711
  • Fax: 719-543-0171
Mailing address:
  • Phone: 719-543-8711
  • Fax: 719-585-3057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: PHILLIP L DAVIS
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 719-543-8718