Healthcare Provider Details

I. General information

NPI: 1497792816
Provider Name (Legal Business Name): PUEBLO NEUROSCIENCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 04/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 E ORMAN AVE SUITE G32
PUEBLO CO
81004-3537
US

IV. Provider business mailing address

1925 E ORMAN AVE SUITE G32
PUEBLO CO
81004-3537
US

V. Phone/Fax

Practice location:
  • Phone: 719-564-0883
  • Fax: 719-564-0861
Mailing address:
  • Phone: 719-564-0883
  • Fax: 719-564-0861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. SUMANT RAWAT
Title or Position: OWNER
Credential: M.D.
Phone: 719-564-0883