Provider Demographics
NPI:1962553172
Name:CHILDREN'S CLINIC OF PUEBLO, PC
Entity type:Organization
Organization Name:CHILDREN'S CLINIC OF PUEBLO, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LORAINE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-295-2305
Mailing Address - Street 1:1600 N GRAND AVE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2700
Mailing Address - Country:US
Mailing Address - Phone:719-295-2305
Mailing Address - Fax:719-295-2320
Practice Address - Street 1:1600 N GRAND AVE
Practice Address - Street 2:SUITE 240
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2700
Practice Address - Country:US
Practice Address - Phone:719-295-2305
Practice Address - Fax:719-295-2320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36942208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO49708864Medicaid
CH636086OtherBCBS