Provider Demographics
NPI:1235620840
Name:SSC PUEBLO OPERATING COMPANY LLC
Entity Type:Organization
Organization Name:SSC PUEBLO OPERATING COMPANY LLC
Other - Org Name:MINNEQUA MEDICENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PITTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-467-6793
Mailing Address - Street 1:5300 W SAM HOUSTON PKWY N STE 100
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77041-5162
Mailing Address - Country:US
Mailing Address - Phone:832-467-6000
Mailing Address - Fax:
Practice Address - Street 1:2701 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3869
Practice Address - Country:US
Practice Address - Phone:719-561-1300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSC PUEBLO OPERATING COMPANY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0004385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000160668Medicaid