Basic Information
| Provider Information | |||||||||
| NPI: | 1003899022 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VALLEY-WIDE HEALTH SYSTEMS, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SAN LUIS REHAB & PT SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | UNIT 1 B AT 233 MAIN STREET | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | SAN LUIS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811520328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196723352 | ||||||||
| FaxNumber: | 7196723638 | ||||||||
| Practice Location | |||||||||
| Address1: | UNIT 1 B AT 233 MAIN STREET | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | SAN LUIS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811520328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196723352 | ||||||||
| FaxNumber: | 7196723638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ARNOLDI | ||||||||
| AuthorizedOfficialFirstName: | JANIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 7195895161 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | CO | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 261QF0400X | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 13984772 | 05 | CO | MEDICAID | VAC 4808 | 01 | CO | ANTHEM BCBS | OTHER | CE 9669 | 01 | CO | TRAVELERS MEDICARE | OTHER |