Provider Demographics
NPI:1821010448
Name:PUEBLO COMMUNITY HEALTH CENTER INC.
Entity Type:Organization
Organization Name:PUEBLO COMMUNITY HEALTH CENTER INC.
Other - Org Name:
Other - Org Type:
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:CEO
Authorized Official - Phone:719-543-8711
Mailing Address - Street 1:310 COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004
Mailing Address - Country:US
Mailing Address - Phone:719-543-8718
Mailing Address - Fax:719-543-5340
Practice Address - Street 1:328 AVONDALE BLVD
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:CO
Practice Address - Zip Code:81022
Practice Address - Country:US
Practice Address - Phone:719-543-8711
Practice Address - Fax:719-543-5340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0849261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05638275Medicaid
CO05638275Medicaid
061832Medicare Oscar/Certification