Provider Demographics
NPI:1487862835
Name:PUEBLO AUDIOLOGY CENTER
Entity Type:Organization
Organization Name:PUEBLO AUDIOLOGY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:TY
Authorized Official - Middle Name:
Authorized Official - Last Name:SQUIRES
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC
Authorized Official - Phone:719-542-1760
Mailing Address - Street 1:712 FORTINO BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2084
Mailing Address - Country:US
Mailing Address - Phone:719-542-1760
Mailing Address - Fax:719-542-5115
Practice Address - Street 1:712 FORTINO BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2084
Practice Address - Country:US
Practice Address - Phone:719-542-1760
Practice Address - Fax:719-542-5115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO14421739Medicaid
PU668438OtherBCBS
P00200291OtherRR MEDICARE PIN
DC9518OtherRR MEDICARE
COC521648Medicare PIN