Provider Demographics
NPI:1124239991
Name:PUEBLO VASCULAR DIAGNOSTICS, INC
Entity type:Organization
Organization Name:PUEBLO VASCULAR DIAGNOSTICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARI
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCWHIRTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-419-0685
Mailing Address - Street 1:PO BOX 479
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81002-0479
Mailing Address - Country:US
Mailing Address - Phone:719-545-1607
Mailing Address - Fax:
Practice Address - Street 1:1619 N GREENWOOD ST STE 318
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2644
Practice Address - Country:US
Practice Address - Phone:716-545-1607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPU660277OtherBLUE CROSS BLUE SHIELD
CO63281279Medicaid
COC480338Medicare ID - Type Unspecified