Healthcare Provider Details

I. General information

NPI: 1659939403
Provider Name (Legal Business Name): PUEBLO WEST PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 S PURCELL BLVD STE 140
PUEBLO WEST CO
81007-5123
US

IV. Provider business mailing address

141 S PURCELL BLVD STE 140
PUEBLO WEST CO
81007-5123
US

V. Phone/Fax

Practice location:
  • Phone: 719-281-9587
  • Fax: 719-960-2054
Mailing address:
  • Phone: 719-281-9587
  • Fax: 719-960-2054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TERRI SHAWCROFT
Title or Position: OFFICE MANAGER
Credential:
Phone: 719-251-9465