Healthcare Provider Details

I. General information

NPI: 1972556744
Provider Name (Legal Business Name): LUTHERAN HOSPITAL ASSOCIATION OF THE SAN LUIS VALLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 STUART AVE
ALAMOSA CO
81101-2269
US

IV. Provider business mailing address

106 BLANCA AVE
ALAMOSA CO
81101-2340
US

V. Phone/Fax

Practice location:
  • Phone: 719-589-3000
  • Fax: 719-587-1372
Mailing address:
  • Phone: 719-589-3000
  • Fax: 719-587-1372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number011001
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number011001
License Number StateCO

VIII. Authorized Official

Name: MRS. KONNIE MARTIN
Title or Position: C.E.O.
Credential:
Phone: 719-587-1206