Provider Demographics
NPI:1184866410
Name:LUTHERAN HOSPITAL ASSOCIATION OF THE SAN LUIS VALLEY
Entity Type:Organization
Organization Name:LUTHERAN HOSPITAL ASSOCIATION OF THE SAN LUIS VALLEY
Other - Org Name:SLV REGIONAL MEDICAL CENTER PHYSICIAN SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:W
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:719-587-1200
Mailing Address - Street 1:106 BLANCA AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2340
Mailing Address - Country:US
Mailing Address - Phone:719-589-2511
Mailing Address - Fax:719-587-1372
Practice Address - Street 1:103 CHICO CT
Practice Address - Street 2:SUITE B
Practice Address - City:MONTE VISTA
Practice Address - State:CO
Practice Address - Zip Code:81144-1065
Practice Address - Country:US
Practice Address - Phone:719-852-7240
Practice Address - Fax:719-852-0332
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SLV REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO68085770Medicaid