Provider Demographics
NPI:1659939403
Name:PUEBLO WEST PRIMARY CARE LLC
Entity Type:Organization
Organization Name:PUEBLO WEST PRIMARY CARE LLC
Other - Org Name:PUEBLO WEST PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAWCROFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-251-9465
Mailing Address - Street 1:141 S PURCELL BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-5123
Mailing Address - Country:US
Mailing Address - Phone:719-281-9587
Mailing Address - Fax:719-960-2054
Practice Address - Street 1:141 S PURCELL BLVD STE 140
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-5123
Practice Address - Country:US
Practice Address - Phone:719-281-9587
Practice Address - Fax:719-960-2054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-05
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty