Healthcare Provider Details

I. General information

NPI: 1497713960
Provider Name (Legal Business Name): PUEBLO IMAGING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 W 12TH ST
PUEBLO CO
81003-2815
US

IV. Provider business mailing address

404 W 12TH ST
PUEBLO CO
81003-2815
US

V. Phone/Fax

Practice location:
  • Phone: 719-542-0172
  • Fax: 719-542-5072
Mailing address:
  • Phone: 719-542-0172
  • Fax: 719-542-5072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number5047
License Number StateCO

VIII. Authorized Official

Name: MRS. LARAE ANN MILLER
Title or Position: CENTER MANAGER
Credential:
Phone: 719-542-0172