Healthcare Provider Details

I. General information

NPI: 1457706483
Provider Name (Legal Business Name): PUEBLO DIVERSIFIED INDUSTRIES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2016
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828 GRANADA BLVD
PUEBLO CO
81005-3104
US

IV. Provider business mailing address

2828 GRANADA BLVD
PUEBLO CO
81005-3104
US

V. Phone/Fax

Practice location:
  • Phone: 719-564-0000
  • Fax:
Mailing address:
  • Phone: 719-564-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: BRYANA BURNS
Title or Position: CFO
Credential:
Phone: 719-564-0000