Healthcare Provider Details

I. General information

NPI: 1225373418
Provider Name (Legal Business Name): PUEBLO CARE AND REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2012
Last Update Date: 06/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 JONES AVE
PUEBLO CO
81004-2650
US

IV. Provider business mailing address

2611 JONES AVE
PUEBLO CO
81004-2650
US

V. Phone/Fax

Practice location:
  • Phone: 719-544-4408
  • Fax: 719-566-1960
Mailing address:
  • Phone: 719-544-4408
  • Fax: 719-566-1960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1401044
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number1401044
License Number StateCO

VIII. Authorized Official

Name: KAREN WILSON WILSON
Title or Position: CERTIFIED OT ASSISTANT/COTA
Credential: CERTIFICATION
Phone: 719-544-4408