Provider Demographics
NPI:1972556744
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 STUART AVENUE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.E.O.
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:719-589-3000
Mailing Address - Fax:719-587-1372
Practice Address - Street 1:2115 STUART AVE
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2269
Practice Address - Country:US
Practice Address - Phone:719-589-3000
Practice Address - Fax:719-587-1372
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUTHERAN HOSPITAL ASSOCIATION OF THE SAN LUIS VALLEY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-19
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO011001111N00000X, 207R00000X
207Q00000X, 207X00000X, 208100000X, 2083P0500X, 2084P0800X, 363A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - 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
CO11777869Medicaid
COC546498Medicare PIN