Provider Demographics
NPI:1235181744
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:SAN LUIS VALLEY HEALTH REGIONAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-587-1206
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 1:106 BLANCA AVE
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2340
Practice Address - Country:US
Practice Address - Phone:719-589-2511
Practice Address - Fax:719-587-1372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO011001282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04107041Medicaid
CO04003141Medicaid
CO06000426Medicaid
CO05008008Medicaid
CO06000426Medicaid
CO060008Medicare Oscar/Certification
CO04107041Medicaid
CD6461Medicare Oscar/Certification