NPIMap

Organization Active NPI

Lutheran Hospital Association of the San Luis Valley

Doing business as San Luis ValleyHealth Monte Vista Community Clinic

  • Family Medicine Physician
  • Monte Vista, CO
National Provider Identifier
1083012504
Registry record updated May 26, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
011001 Issued in CO
Legal business name
LUTHERAN HOSPITAL ASSOCIATION OF THE SAN LUIS VALLEY
Doing business as
San Luis ValleyHealth Monte Vista Community Clinic
Practice address
103 Chico CT
Monte Vista, CO 81144-1065
Phone
(719) 852-9400
Fax
(719) 852-9311
NPI assigned
Dec 16, 2014
Last updated
May 26, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 26, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Konni Martin
Title
Ceo
Phone
(719) 587-1206

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 011001 CO
Chiropractor 111N00000X 011001 CO
Family Medicine Physician 207Q00000X 011001 CO Primary
Psychiatry Physician 2084P0800X 011001 CO

Addresses

Primary practice location

103 Chico CT
Monte Vista, CO 81144-1065

Mailing address

106 Blanca Ave
Alamosa, CO 81101-2340
Phone (719) 589-2511

Other identifiers 1

IdentifierTypeStateIssuer
9000144694MedicaidCO

Other names 1

  • San Luis ValleyHealth Monte Vista Community Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150227001476 CO Part A Provider - Rural Health Clinic 4789589094 Practice locations: Monte Vista, CO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1083012504. Details of each certification follow.

Rural health clinic certification: CCN 068523

Legal name
LUTHERAN HOSPITAL ASSOCIATION OF THE SAN LUIS VALLEY
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
May 14, 2015
Last certification
Jul 19, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 27, 1937 in CO
Enrollment address
103 Chico Court
Monte Vista, CO 81144-1065
Related CCNs
060008

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 6

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
06D2342653San Luis Valley Monte Vista Community Clinic103 Chico Court, Monte Vista, CO 81144Provider-performed microscopyApr 22, 2028

National Provider Directory

National Provider Directory
Tax ID family
Slvrmc Prof Comp11 organizations share this tax ID, including this one

Other organizations with this tax ID 10

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 6

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Karla Hardesty Individual Corporate DirectorBoard President May 2, 2011
Christine Hettinger Hunt Individual W-2 Managing EmployeeCno Jan 1, 2019
Shane Mortensen Individual Corporate OfficerCfo May 2, 2011
W-2 Managing EmployeeCfo May 2, 2011
Lutheran Hospital Association of the San Luis Valley Organization, Alamosa, CO Non-profit 5% Or Greater Direct Ownership Interest May 2, 2011 100%
Carmelo Hernandez Individual Corporate OfficerCmo Jan 1, 2019
W-2 Managing EmployeeCmo Jan 1, 2019
Konnie Martin Individual Corporate OfficerCeo Jul 1, 2013
W-2 Managing EmployeeCeo Jul 1, 2013
Operational/Managerial ControlCeo Jul 1, 2013

Owners & managing parties with NPI records 7

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 4

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
San Luis Valley HealthLa Jara, CO, CCN 061308 Hospital 5% Or Greater Direct Ownership Interest (100%) Jul 1, 2013
SLV Health Conejos County Hospital Swing BedLa Jara, CO, CCN 06Z308 Hospital 5% Or Greater Direct Ownership Interest (100%) Jul 1, 2013
SLV Health Antonito ClinicAntonito, CO, CCN 063992 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Jul 1, 2013
SLV Health la Jara ClinicLa Jara, CO, CCN 068513 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Jul 1, 2013

Owned or controlled facilities with NPI records 4

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 4

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1418688000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1685059200000",
    "number": "1083012504",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "106 BLANCA AVE",
            "city": "ALAMOSA",
            "state": "CO",
            "postal_code": "811012340",
            "telephone_number": "719-589-2511",
            "fax_number": "719-587-1372"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "103 CHICO CT",
            "city": "MONTE VISTA",
            "state": "CO",
            "postal_code": "811441065",
            "telephone_number": "719-852-9400",
            "fax_number": "719-852-9311"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LUTHERAN HOSPITAL ASSOCIATION OF THE SAN LUIS VALLEY",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-12-16",
        "last_updated": "2023-05-26",
        "certification_date": "2023-05-26",
        "status": "A",
        "authorized_official_last_name": "MARTIN",
        "authorized_official_first_name": "KONNI",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "719-587-1206"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "CO",
            "license": "011001",
            "primary": false
        },
        {
            "code": "111N00000X",
            "taxonomy_group": "",
            "desc": "Chiropractor",
            "state": "CO",
            "license": "011001",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "CO",
            "license": "011001",
            "primary": true
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "CO",
            "license": "011001",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "9000144694",
            "state": "CO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "San Luis ValleyHealth Monte Vista Community Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "San Luis ValleyHealth Monte Vista Community Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Monte Vista, CO

Sources for this page

Verify at the official NPI Registry.