1063013860 NPI number — PUEBLO RADIOLOGICAL GROUP, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063013860 NPI number — PUEBLO RADIOLOGICAL GROUP, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUEBLO RADIOLOGICAL GROUP, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063013860
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7693
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOVELAND
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80537-0693
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-663-2742
Provider Business Mailing Address Fax Number:
970-342-2093

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
245 BALMORAL WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80906-7907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-584-7410
Provider Business Practice Location Address Fax Number:
719-542-7019
Provider Enumeration Date:
11/06/2020

Additional Information

Authorized Official

Authorized Official Last Name:
BOYER
Authorized Official First Name:
ROBIN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
AUTH REP/DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
970-663-2742

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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