Provider Demographics
NPI:1497713960
Name:PUEBLO IMAGING CENTER, LLC
Entity Type:Organization
Organization Name:PUEBLO IMAGING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CENTER MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LARAE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-542-0172
Mailing Address - Street 1:404 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2815
Mailing Address - Country:US
Mailing Address - Phone:719-542-0172
Mailing Address - Fax:719-542-5072
Practice Address - Street 1:404 W 12TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2815
Practice Address - Country:US
Practice Address - Phone:719-542-0172
Practice Address - Fax:719-542-5072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5047174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO31789013Medicaid
COG08554Medicare UPIN
CO31789013Medicaid
COG17227Medicare UPIN
CO506708Medicare ID - Type Unspecified
COM39448Medicare UPIN
COR82362Medicare UPIN
C3208Medicare UPIN