1497713960 NPI number — PUEBLO IMAGING CENTER, LLC

Table of content: (NPI 1497713960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497713960 NPI number — PUEBLO IMAGING CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUEBLO IMAGING CENTER, LLC
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:
1497713960
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
404 W 12TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81003-2815
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-542-0172
Provider Business Mailing Address Fax Number:
719-542-5072

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
404 W 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81003-2815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-542-0172
Provider Business Practice Location Address Fax Number:
719-542-5072
Provider Enumeration Date:
05/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
LARAE
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
CENTER MANAGER
Authorized Official Telephone Number:
719-542-0172

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  5047 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 31789013 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com