Provider Demographics
NPI:1831557917
Name:AMISTAD OF SAN LUIS, INC
Entity type:Organization
Organization Name:AMISTAD OF SAN LUIS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FUNK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-588-9903
Mailing Address - Street 1:403 MAIN STREET
Mailing Address - Street 2:P.O.BOX 674
Mailing Address - City:SAN LUIS
Mailing Address - State:CO
Mailing Address - Zip Code:81152-0674
Mailing Address - Country:US
Mailing Address - Phone:719-672-0892
Mailing Address - Fax:719-672-0892
Practice Address - Street 1:403 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:CO
Practice Address - Zip Code:81152-0674
Practice Address - Country:US
Practice Address - Phone:719-672-0892
Practice Address - Fax:719-672-0892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO68058217Medicaid