Basic Information
Provider Information | |||||||||
NPI: | 1902290521 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAN LUIS VALLEY COMMUNITY MENTAL HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SAN LUIS VALLEY BEHAVIORAL HEALTH GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 03/20/2015 | ||||||||
LastUpdateDate: | 05/11/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARTINEZ | ||||||||
AuthorizedOfficialFirstName: | FERNANDO | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7195893671 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 261Q00000X | 15K557 | CO | N |   | Ambulatory Health Care Facilities | Clinic/Center |   | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 04140091 | 05 | CO |   | MEDICAID |