Provider Demographics
NPI:1063280568
Name:PUEBLO MEDICAL CLINIC
Entity type:Organization
Organization Name:PUEBLO MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:QUENTIN
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:520-622-8384
Mailing Address - Street 1:3535 S 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713-5914
Mailing Address - Country:US
Mailing Address - Phone:520-622-8384
Mailing Address - Fax:
Practice Address - Street 1:3535 S 12TH AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-5914
Practice Address - Country:US
Practice Address - Phone:520-622-8384
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center