Provider Demographics
NPI:1023325842
Name:LOVELACE HEALTH SYSTEM LLC
Entity type:Organization
Organization Name:LOVELACE HEALTH SYSTEM LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP
Authorized Official - Prefix:MR
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 1:1692 HOSPITAL DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4754
Mailing Address - Country:US
Mailing Address - Phone:505-982-6399
Mailing Address - Fax:505-727-9404
Practice Address - Street 1:1692 HOSPITAL DR
Practice Address - Street 2:SUITE 202
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4754
Practice Address - Country:US
Practice Address - Phone:505-982-6399
Practice Address - Fax:505-727-9404
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARDENT LEGACY HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-01
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMAPPLIED FOR225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMAPPLIED FORMedicare UPIN