Healthcare Provider Details

I. General information

NPI: 1013271329
Provider Name (Legal Business Name): PUEBLO COMMUNITY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 07/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 COLORADO AVE
PUEBLO CO
81004-2006
US

IV. Provider business mailing address

110 E ROUTT AVE
PUEBLO CO
81004-2117
US

V. Phone/Fax

Practice location:
  • Phone: 719-543-8711
  • Fax: 719-543-5340
Mailing address:
  • Phone: 719-543-8711
  • Fax: 719-543-5340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number50145
License Number StateCO

VIII. Authorized Official

Name: DONNALD MOORE
Title or Position: CEO
Credential:
Phone: 719-543-8711