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General NPI Number Information
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NPI Number | 1497713960
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Entity Type | Organization
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Legal Business Name | PUEBLO IMAGING CENTER, LLC
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Dates
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Enumeration Date | 05/03/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 404 W 12TH ST
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City | PUEBLO
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State | CO
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Zip | 81003-2815
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Country | US
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Telephone | 719-542-0172
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Fax | 719-542-5072
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Provider Business Mailing Address
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Address Line | 404 W 12TH ST
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City | PUEBLO
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State | CO
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Zip | 81003-2815
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Country | US
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Telephone | 719-542-0172
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Fax | 719-542-5072
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Authorized Official
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Title or Position | CENTER MANAGER
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Name | MRS. LARAE ANN MILLER
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Credential |
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Telephone | 719-542-0172
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 5047
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License Number State | CO
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