Provider Demographics
NPI:1376595504
Name:ENT CLINIC OF PUEBLO PROF LLC
Entity Type:Organization
Organization Name:ENT CLINIC OF PUEBLO PROF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:J
Authorized Official - Last Name:HICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-544-3752
Mailing Address - Street 1:1304 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2759
Mailing Address - Country:US
Mailing Address - Phone:719-544-3752
Mailing Address - Fax:719-542-1794
Practice Address - Street 1:1304 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2759
Practice Address - Country:US
Practice Address - Phone:719-544-3752
Practice Address - Fax:719-542-1794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO78674247Medicaid
CO502258Medicare ID - Type Unspecified