=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356088595
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PUEBLO CHEMICAL AGENT-DESTRUCTION PILOT PLANT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2022
-----------------------------------------------------
Last Update Date | 05/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45825 E STATE HIGHWAY 96
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81006-9330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-549-5483
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 45825 E STATE HIGHWAY 96
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81006-9330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-549-5483
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. PAUL GLENN MERCHANT JR.
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 719-549-5483
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QX0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------