Provider Demographics
NPI:1316213606
Name:LOVELACE HEALTH SYSTEM INC
Entity Type:Organization
Organization Name:LOVELACE HEALTH SYSTEM INC
Other - Org Name:LOVELACE REGIONAL HOSPITAL FAMILY AND URGENT CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-296-3000
Mailing Address - Street 1:2335 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-6452
Mailing Address - Country:US
Mailing Address - Phone:575-622-4665
Mailing Address - Fax:575-622-4557
Practice Address - Street 1:2335 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-6452
Practice Address - Country:US
Practice Address - Phone:575-622-4665
Practice Address - Fax:575-622-4557
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARDENT LEGACY HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-30
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM7707576Medicaid