Healthcare Provider Details

I. General information

NPI: 1700247228
Provider Name (Legal Business Name): HV PUEBLO SOUTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 S PUEBLO BLVD
PUEBLO CO
81005-2103
US

IV. Provider business mailing address

2221 E BIJOU ST STE 100
COLORADO SPRINGS CO
80909
US

V. Phone/Fax

Practice location:
  • Phone: 719-281-2633
  • Fax: 719-281-2634
Mailing address:
  • Phone: 719-281-2633
  • Fax: 719-281-2634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. SAMANTHA B LEBLANC
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 719-323-2372