Provider Demographics
NPI:1164468336
Name:PUEBLO COMMUNITY HEALTH CENTER INC.
Entity Type:Organization
Organization Name:PUEBLO COMMUNITY HEALTH CENTER INC.
Other - Org Name:PARKHILL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:719-543-8718
Mailing Address - Street 1:110 E ROUTT AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-2117
Mailing Address - Country:US
Mailing Address - Phone:719-543-8718
Mailing Address - Fax:719-543-5340
Practice Address - Street 1:1302 E 5TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-3754
Practice Address - Country:US
Practice Address - Phone:719-543-8711
Practice Address - Fax:719-543-5340
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PUEBLO COMMUNITY HEALTH CENTER INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-22
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0849261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05638275Medicaid
COCR9008Medicare PIN
CO05638275Medicaid