1821057860 NPI number — LUTHERAN HOSPITAL ASSOCIATION OF THE SAN LUIS VALLEY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821057860 NPI number — LUTHERAN HOSPITAL ASSOCIATION OF THE SAN LUIS VALLEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUTHERAN HOSPITAL ASSOCIATION OF THE SAN LUIS VALLEY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SLV HEALTH ANTONITO CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821057860
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19021 US HIGHWAY 285
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA JARA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-274-5121
Provider Business Mailing Address Fax Number:
719-274-6003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANTONITO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81120-0087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-376-2308
Provider Business Practice Location Address Fax Number:
719-376-2395
Provider Enumeration Date:
03/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
KONNIE
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
CCH CEO
Authorized Official Telephone Number:
719-587-1206

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 93388560 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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