Provider Demographics
NPI:1942511019
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 LA JARA CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CCH CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-274-6004
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:81140-9410
Mailing Address - Country:US
Mailing Address - Phone:719-274-5000
Mailing Address - Fax:719-274-4111
Practice Address - Street 1:509 MAIN STREET
Practice Address - Street 2:
Practice Address - City:LA JARA
Practice Address - State:CO
Practice Address - Zip Code:81140
Practice Address - Country:US
Practice Address - Phone:719-274-5000
Practice Address - Fax:719-274-4111
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUTHERAN HOSPITAL ASSOCIATION OF THE SAN LUIS VALLEY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-23
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO011020261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO55601359Medicaid
CO1376504092OtherPREVIOUS NPI NUMBER
CO1376504092OtherPREVIOUS NPI NUMBER