Provider Demographics
NPI:1790966174
Name:PUEBLO COMMUNITY HEALTH CENTER INC
Entity Type:Organization
Organization Name:PUEBLO COMMUNITY HEALTH CENTER INC
Other - Org Name:WALSENBURG CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-543-8718
Mailing Address - Street 1:110 E ROUTT AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-2117
Mailing Address - Country:US
Mailing Address - Phone:719-543-8711
Mailing Address - Fax:719-585-3057
Practice Address - Street 1:129 KANSAS AVE
Practice Address - Street 2:
Practice Address - City:WALSENBURG
Practice Address - State:CO
Practice Address - Zip Code:81089-1818
Practice Address - Country:US
Practice Address - Phone:719-738-2718
Practice Address - Fax:719-738-2732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO180635261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05638275Medicaid
COCR9008Medicare PIN
CO061898Medicare Oscar/Certification