Provider Demographics
NPI:1134205859
Name:PUEBLO GOODWILL INDUSTRIES HOME CARE PROGRAM
Entity type:Organization
Organization Name:PUEBLO GOODWILL INDUSTRIES HOME CARE PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:ARAGON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-543-5718
Mailing Address - Street 1:247 S SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-4220
Mailing Address - Country:US
Mailing Address - Phone:719-543-5718
Mailing Address - Fax:719-543-5723
Practice Address - Street 1:247 S SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-4220
Practice Address - Country:US
Practice Address - Phone:719-543-5718
Practice Address - Fax:719-543-5723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04138483Medicaid