Healthcare Provider Details

I. General information

NPI: 1417191586
Provider Name (Legal Business Name): DEPARTMENT OF VETERANS AFFAIRS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2009
Last Update Date: 04/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4112 OUTLOOK BLVD
PUEBLO CO
81008-1667
US

IV. Provider business mailing address

4112 OUTLOOK BLVD
PUEBLO CO
81008-1667
US

V. Phone/Fax

Practice location:
  • Phone: 719-553-1000
  • Fax:
Mailing address:
  • Phone: 719-553-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number985013
License Number StateCO

VIII. Authorized Official

Name: IGNACIO GARCIA/BAROS
Title or Position: SOCIAL WORK
Credential: LCSW
Phone: 719-553-1000