Provider Demographics
NPI:1821057860
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 HEALTH ANTONITO CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CCH CEO
Authorized Official - Prefix:
Authorized Official - First Name:KONNIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-587-1206
Mailing Address - Street 1:19021 US HIGHWAY 285
Mailing Address - Street 2:
Mailing Address - City:LA JARA
Mailing Address - State:CO
Mailing Address - Zip Code:81140
Mailing Address - Country:US
Mailing Address - Phone:719-274-5121
Mailing Address - Fax:719-274-6003
Practice Address - Street 1:115 MAIN STREET
Practice Address - Street 2:
Practice Address - City:ANTONITO
Practice Address - State:CO
Practice Address - Zip Code:81120-0087
Practice Address - Country:US
Practice Address - Phone:719-376-2308
Practice Address - Fax:719-376-2395
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUTHERAN HOSPITAL ASSOCIATION OF THE SAN LUIS VALLEY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-20
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO93388560Medicaid
CO72081228Medicaid