NPIMap

Organization Active NPI

Pueblo Community Health Center, Inc

  • Federally Qualified Health Center (FQHC)
  • Pueblo, CO
National Provider Identifier
1144589425
Registry record updated Sep 6, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
180635 Issued in CO
Legal business name
PUEBLO COMMUNITY HEALTH CENTER, INC
Practice address
1008 N Grand Ave
Pueblo, CO 81003-2916
Phone
(719) 543-8718
NPI assigned
May 8, 2012
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 6, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Donald Moore
Title
Ceo
Phone
(719) 543-8718

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 180635 CO Primary

Addresses

Primary practice location

1008 N Grand Ave
Pueblo, CO 81003-2916

Mailing address

110 E Routt Ave
Pueblo, CO 81004-2117
Phone (719) 543-8718

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20130603000038 CO Part A Provider - Federally Qualified Health Center (FQHC) 4284543802 Practice locations: Pueblo, CO

Federally qualified health center certification: CCN 061937

Legal name
PUEBLO COMMUNITY HEALTH CENTER INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 4, 2013
Last certification
Jun 4, 2013
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Incorporated
Aug 24, 1983 in CO
Enrollment address
1008 N. Grand Ave
Pueblo, CO 81003

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Pueblo Community Health17 organizations share this tax ID, including this one

Other organizations with this tax ID 16

Organizations that report the same tax identification number in the National Provider Directory.

View all 16

Locations

1008 N Grand Ave
Pueblo, CO 81003
Phone (719) 543-8718

Ownership & related parties

All disclosed owners & managing parties 11

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Louis B. Balizet Individual Other Oct 1, 2020
Rosina Y Beascochea Individual Other May 1, 2021
Arthur L Yarbrough Individual OtherBoard Member Jan 1, 2012 5%
Steven Shirley Individual Other Dec 1, 2019
Donald Moore Individual 5% Or Greater Indirect Ownership InterestChief Executive Officer Oct 2, 2009 9%
Corporate OfficerCeo Oct 2, 2009
Operational/Managerial ControlChief Executive Officer Oct 2, 2009
Shirley Cordova Individual Other Jun 1, 2013
Phillip Lee Davis Individual Corporate DirectorChief Financial Officer Nov 5, 2020
W-2 Managing EmployeeChief Financial Officer Nov 5, 2020
Operational/Managerial ControlChief Financial Officer Nov 5, 2020
Tracy Phillips Individual Other Jul 1, 2022
Sandra K Leming Individual Other May 1, 2021
Michael Gage Individual Other Apr 1, 2017
Linda Rikhoff Individual Other Jun 1, 2017

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Pueblo Community Health CenterPueblo, CO, CCN 061031 Federally qualified health center Other May 1, 2018

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 66

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 66

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1336435200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1378425600000",
    "number": "1144589425",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "110 E ROUTT AVE",
            "city": "PUEBLO",
            "state": "CO",
            "postal_code": "810042117",
            "telephone_number": "719-543-8718",
            "fax_number": "719-543-5340"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1008 N GRAND AVE",
            "city": "PUEBLO",
            "state": "CO",
            "postal_code": "810032916",
            "telephone_number": "719-543-8718"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PUEBLO COMMUNITY HEALTH CENTER, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-05-08",
        "last_updated": "2013-09-06",
        "status": "A",
        "authorized_official_last_name": "MOORE",
        "authorized_official_first_name": "DONALD",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "719-543-8718"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "CO",
            "license": "180635",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Pueblo, CO

Sources for this page

Verify at the official NPI Registry.