Healthcare Provider Details

I. General information

NPI: 1124239991
Provider Name (Legal Business Name): PUEBLO VASCULAR DIAGNOSTICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 N GREENWOOD ST STE 318
PUEBLO CO
81003-2644
US

IV. Provider business mailing address

PO BOX 479
PUEBLO CO
81002-0479
US

V. Phone/Fax

Practice location:
  • Phone: 716-545-1607
  • Fax:
Mailing address:
  • Phone: 719-545-1607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. KARI A MCWHIRTER
Title or Position: OWNER
Credential:
Phone: 505-419-0685