Provider Demographics
NPI:1568534642
Name:PUEBLO BONE AND JOINT CLINIC LLC
Entity Type:Organization
Organization Name:PUEBLO BONE AND JOINT CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-253-7102
Mailing Address - Street 1:1919 W US HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1618
Mailing Address - Country:US
Mailing Address - Phone:719-253-7102
Mailing Address - Fax:719-253-7114
Practice Address - Street 1:1919 W US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1618
Practice Address - Country:US
Practice Address - Phone:719-253-7102
Practice Address - Fax:719-253-7114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO50330349Medicaid
COC446648Medicare PIN
CO5410910001Medicare NSC