Basic Information
| Provider Information | |||||||||
| NPI: | 1063406999 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN LUIS VALLEY COMMUNITY MENTAL HEALTH CENTER | ||||||||
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| OtherOrganizationName: | SAN LUIS VALLEY BEHAVIORAL HEALTH GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8745 COUNTY ROAD 9 SOUTH | ||||||||
| Address2: | |||||||||
| City: | ALAMOSA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195893671 | ||||||||
| FaxNumber: | 7195899136 | ||||||||
| Practice Location | |||||||||
| Address1: | 8745 COUNTY ROAD 9 S | ||||||||
| Address2: | |||||||||
| City: | ALAMOSA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811019610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195893671 | ||||||||
| FaxNumber: | 7195899136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | MARTINEZ | ||||||||
| AuthorizedOfficialFirstName: | FERNANDO | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7195893671 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 15K557 | CO | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1063406999 | 05 | CO | MEDICAID |