Provider Demographics
NPI:1639281439
Name:QUALICENTERS PUEBLO, LLC
Entity Type:Organization
Organization Name:QUALICENTERS PUEBLO, LLC
Other - Org Name:FRESENIUS MEDICAL CARE LA JUNTA DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:1012 HAYES AVE
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-2107
Mailing Address - Country:US
Mailing Address - Phone:719-383-2300
Mailing Address - Fax:719-383-2302
Practice Address - Street 1:1012 HAYES AVE
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-2107
Practice Address - Country:US
Practice Address - Phone:719-383-2300
Practice Address - Fax:719-383-2302
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-31
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO062525Medicare Oscar/Certification