Organization
PUEBLO AUDIOLOGY CENTER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TY SQUIRES MS, CCC (AUDIOLOGIST)
(719) 542-1760
Entity
Organization
Contact information
Practice address
712 FORTINO BLVD, SUITE D, PUEBLO, CO 81008-2084
(719) 542-1760
(719) 542-5115
Mailing address
712 FORTINO BLVD, SUITE D, PUEBLO, CO 81008-2084
(719) 542-1760
(719) 542-5115
Taxonomy
Speciality
Code
Description
License number
State
231H00000X
Audiologist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
14421739
—
CO
01
—
DC9518
RR MEDICARE
—
01
—
P00200291
RR MEDICARE PIN
—
01
—
PU668438
BCBS
—
Enumeration date
05/18/2007
Last updated
04/01/2008
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