NPIMap

Organization Active NPI

Pueblo Community Health Center Inc

  • Federally Qualified Health Center (FQHC)
  • Pueblo, CO
National Provider Identifier
1316466816
Registry record updated Sep 15, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
PUEBLO COMMUNITY HEALTH CENTER INC
Practice address
900 W Orman Ave RM Mt118
Pueblo, CO 81004-1430
Phone
(719) 543-8711
NPI assigned
Sep 15, 2017
Last updated
Sep 15, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 15, 2017

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

Authorized official

Name
Pauline Trujillo
Title
Patient Accounts Manager
Phone
(719) 543-8711

Specialties & licenses 1

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

Addresses

Primary practice location

900 W Orman Ave RM Mt118
Pueblo, CO 81004-1430

Mailing address

110 E Routt Ave
Pueblo, CO 81004-2117
Phone (719) 543-8711

Other names 1

  • Pueblo Community College Health Clinic Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CO2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031104000171 CO Part B Supplier - Clinic/Group Practice 4284543802 Receives reassigned benefits from 167 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Pueblo, CO; Walsenburg, CO; Avondale, CO
O20180522000397 CO Part A Provider - Federally Qualified Health Center (FQHC) 4284543802 Practice locations: Pueblo, CO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1316466816. Details of each certification follow.

Federally qualified health center certification: CCN 061984

Legal name
PUEBLO COMMUNITY HEALTH CENTER INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 15, 2018
Last certification
May 15, 2018
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Incorporated
Aug 24, 1983 in CO
Enrollment address
900 W Orman Ave
RM Mt118
Pueblo, CO 81004-1430

Other NPIs with the same Medicare PAC ID 4

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

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

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

1301 E 7th St
Pueblo, CO 81001
Phone (719) 476-0220

Ownership & related parties

All disclosed owners & managing parties 12

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 Sep 23, 2017
Rosina Y Beascochea Individual Other May 1, 2018
Arthur L Yarbrough Individual Other Jan 10, 2016
Steven Shirley Individual Other Dec 1, 2019
Donald Moore Individual Corporate OfficerChief Executive Officer Oct 2, 2009
Shirley Cordova Individual Other Jan 13, 2016
Phillip Lee Davis Individual Corporate OfficerChief Financial Officer Nov 5, 2020 100%
Operational/Managerial ControlChief Financial Officer Nov 5, 2020 100%
Alexis Stewart Individual Other May 1, 2023
Tracy Phillips Individual Other Jul 1, 2022
Sandra K Leming Individual Other May 1, 2021
Michael Gage Individual Other Mar 20, 2017
Linda Rikhoff Individual Other Jun 6, 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 62

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 62

NPI Registry JSON

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

{
    "created_epoch": "1505433600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1505433600000",
    "number": "1316466816",
    "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": "719-543-8711"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "900 W ORMAN AVE RM MT118",
            "city": "PUEBLO",
            "state": "CO",
            "postal_code": "810041430",
            "telephone_number": "719-543-8711"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PUEBLO COMMUNITY HEALTH CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-09-15",
        "last_updated": "2017-09-15",
        "status": "A",
        "authorized_official_last_name": "TRUJILLO",
        "authorized_official_first_name": "PAULINE",
        "authorized_official_title_or_position": "PATIENT ACCOUNTS MANAGER",
        "authorized_official_telephone_number": "719-543-8711"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Pueblo Community College Health Clinic",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Pueblo, CO

Sources for this page

Verify at the official NPI Registry.