Provider Demographics
NPI:1073181061
Name:PICURIS PUEBLO
Entity Type:Organization
Organization Name:PICURIS PUEBLO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GOVERNOR, PICURIS PUEBLO
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:QUANCHELLO
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW,LADAC,CADC,CS
Authorized Official - Phone:575-587-2519
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:PENASCO
Mailing Address - State:NM
Mailing Address - Zip Code:87553
Mailing Address - Country:US
Mailing Address - Phone:575-587-2519
Mailing Address - Fax:505-579-9129
Practice Address - Street 1:201 A PUEBLO VIEW ROAD
Practice Address - Street 2:
Practice Address - City:PENASCO
Practice Address - State:NM
Practice Address - Zip Code:87553
Practice Address - Country:US
Practice Address - Phone:575-587-2519
Practice Address - Fax:505-579-2660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-15
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No3416L0300XTransportation ServicesAmbulanceLand Transport