Healthcare Provider Details

I. General information

NPI: 1699576587
Provider Name (Legal Business Name): PUEBLO CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2025
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 E 17TH ST STE 6178
CHEYENNE WY
82001-4543
US

IV. Provider business mailing address

109 E 17TH ST STE 6178
CHEYENNE WY
82001-4543
US

V. Phone/Fax

Practice location:
  • Phone: 720-761-1362
  • Fax:
Mailing address:
  • Phone: 720-761-1362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MARIO RAFAEL ANGLADA CORTES
Title or Position: CEO
Credential:
Phone: 720-761-1362