Basic Information
| Provider Information | |||||||||
| NPI: | 1023325842 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LOVELACE HEALTH SYSTEM LLC | ||||||||
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| OtherOrganizationName: | LOVELACE OUTPATIENT REHABILITATION SANTA FE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1692 HOSPITAL DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875054754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059826399 | ||||||||
| FaxNumber: | 5057279404 | ||||||||
| Practice Location | |||||||||
| Address1: | 1692 HOSPITAL DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875054754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059826399 | ||||||||
| FaxNumber: | 5057279404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2010 | ||||||||
| LastUpdateDate: | 02/22/2022 | ||||||||
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| AuthorizedOfficialLastName: | PETROVICH | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP | ||||||||
| AuthorizedOfficialTelephone: | 6152963000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ARDENT LEGACY HOLDINGS, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | APPLIED FOR | NM | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.