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General NPI Number Information
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NPI Number | 1962553172
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Entity Type | Organization
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Legal Business Name | CHILDREN'S CLINIC OF PUEBLO, PC
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Dates
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Enumeration Date | 01/15/2007
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Last Update Date | 12/09/2011
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Provider Practice Location Address
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Address Line | 1600 N GRAND AVE SUITE 240
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City | PUEBLO
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State | CO
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Zip | 81003-2700
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Country | US
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Telephone | 719-295-2305
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Fax | 719-295-2320
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Provider Business Mailing Address
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Address Line | 1600 N GRAND AVE SUITE 240
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City | PUEBLO
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State | CO
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Zip | 81003-2700
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Country | US
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Telephone | 719-295-2305
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Fax | 719-295-2320
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Authorized Official
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Title or Position | PHYSICIAN
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Name | LORAINE L. CARROLL
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Credential | M.D.
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Telephone | 719-295-2305
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 36942
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License Number State | CO
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