Provider Demographics
NPI:1306890793
Name:OLD PUEBLO HEALTHCARE LLC
Entity type:Organization
Organization Name:OLD PUEBLO HEALTHCARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:O'NEIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-660-6706
Mailing Address - Street 1:5981 E GRANT RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712
Mailing Address - Country:US
Mailing Address - Phone:520-886-5315
Mailing Address - Fax:520-298-8201
Practice Address - Street 1:5981 E GRANT RD
Practice Address - Street 2:SUITE 115
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712
Practice Address - Country:US
Practice Address - Phone:520-886-5315
Practice Address - Fax:520-298-8201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN069526363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ101738Medicaid
AZ101738Medicaid