| Details | Last Recertification Date | Update | Recertification | 2/20/2024 3:42:43 PM | 2/11/2025 1:22:54 PM | 2/11/2025 1:22 PM |
| Details | Entity Subname | Update | Recertification | Estes Park Salud Family Health Center | SALUD ESTES PARK | 2/11/2025 1:22 PM |
| Addresses | Billing Address | Update | Recertification | PLAN DE SALUD DEL VALLE, INC.
203 SOUTH ROLLIE AVENUE
FORT LUPTON, CO 80621 | SALUD FAMILY HEALTH, INC
203 SOUTH ROLLIE AVENUE
FORT LUPTON, CO 80621 | 2/20/2024 3:42 PM |
| Details | Last Recertification Date | Update | Recertification | 2/20/2023 11:50:48 AM | 2/20/2024 3:42:43 PM | 2/20/2024 3:42 PM |
| Details | Entity Name | Update | Recertification | PLAN DE SALUD DEL VALLE, INC | SALUD FAMILY HEALTH, INC | 2/20/2024 3:42 PM |
| Details | Last Recertification Date | Update | Recertification | 2/8/2022 11:16:33 AM | 2/20/2023 11:50:48 AM | 2/20/2023 11:50 AM |
| Details | Last Recertification Date | Update | Recertification | 2/9/2021 12:49:04 PM | 2/8/2022 11:16:33 AM | 2/8/2022 11:16 AM |
| Medicaid Billing | Medicaid: Number | Delete | Recertification | 1D04095089 (CO) | | 2/9/2021 12:49 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | CO | 2/9/2021 12:49 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1275530388 ( ) | | 2/9/2021 12:49 PM |
| Details | Last Recertification Date | Update | Recertification | 2/3/2020 1:20:44 PM | 2/9/2021 12:49:04 PM | 2/9/2021 12:49 PM |
| Details | Last Recertification Date | Update | Recertification | 2/11/2019 2:17:39 PM | 2/3/2020 1:20:44 PM | 2/3/2020 1:20 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 2/11/2019 2:17 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 1D04095089 | 2/11/2019 2:17 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | CO | 2/11/2019 2:17 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1275530388 | 2/11/2019 2:17 PM |
| Details | Last Recertification Date | Update | Recertification | 2/28/2018 4:33:46 PM | 2/11/2019 2:17:39 PM | 2/11/2019 2:17 PM |
| Details | Last Recertification Date | Update | Recertification | 2/6/2017 12:00:00 AM | 2/28/2018 4:33:46 PM | 2/28/2018 4:33 PM |
| Contacts | Authorizing Official | Update | | Santistevan, John
President/ CEO
3038926401 | Santistevan, John
President/ CEO
Salud Family Health Centers
3038926401 | 1/11/2018 3:01 PM |
| Contacts | Primary Contact | Update | | Hartman, George
Director of Pharmacy
3038926401 | Hartman, George
Director of Pharmacy
PLAN DE SALUD DEL VALLE
3038926401 | 9/25/2017 1:10 PM |
| Contacts | Authorizing Official | Insert | | | Santistevan, John
President/ CEO
3038926401 | 7/24/2017 1:15 PM |
| Addresses | Main Address | Insert | | |
1950 Redtail Hawk Dr
Estes Park, CO 80517-9780 | 2/16/2017 6:42 PM |
| Contacts | Primary Contact | Update | | LUCIO, PATRICIA
IMMUNIZATION PROGRAM MANAGER
7203229428 | Hartman, George
Director of Pharmacy
3038926401 | 2/16/2017 6:42 PM |
| Details | Last Recertification Date | Update | | 2/12/2016 12:00:00 AM | 2/6/2017 12:00:00 AM | 2/16/2017 6:41 PM |
| Details | Last Recertification Date | Update | | 3/4/2015 12:00:00 AM | 2/12/2016 12:00:00 AM | 2/12/2016 3:53 PM |
| Addresses | Billing Address | Insert | | | PLAN DE SALUD DEL VALLE, INC.
203 SOUTH ROLLIE AVENUE
FORT LUPTON, CO 80621 | 4/22/2015 2:46 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 4/22/2015 2:45 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 05638358 | 4/22/2015 2:45 PM |
| Medicaid Billing | Medicaid: State | Insert | | | CO | 4/22/2015 2:45 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1720111677 | 4/22/2015 2:45 PM |
| Details | Last Recertification Date | Update | | 3/13/2014 12:00:00 AM | 3/4/2015 12:00:00 AM | 3/4/2015 12:52 PM |
| Details | Last Recertification Date | Update | | 4/1/2013 12:00:00 AM | 3/13/2014 12:00:00 AM | 3/13/2014 9:16 PM |
| Details | Entity Name | Update | | PLAN DE SALUD DEL VALLE, INC. | PLAN DE SALUD DEL VALLE, INC | 3/13/2014 9:16 PM |
| Details | Entity Subname | Update | | SALUD FAMILY HEALTH CENTERS - ESTES PARK | Estes Park Salud Family Health Center | 3/13/2014 9:16 PM |
| Details | Last Recertification Date | Update | | | 4/1/2013 12:00:00 AM | 3/15/2013 7:13 AM |
| Details | Comments Public | Insert | | | 3/30/12-Changed primary contact (was PATRICIA LUCIO) | 3/30/2012 10:16 AM |
| Contacts | Primary Contact | Insert | | | LUCIO, PATRICIA
IMMUNIZATION PROGRAM MANAGER
7203229428 | 12/8/2011 2:04 PM |
| Details | Last Recertification Date | Insert | | | | 5/19/2010 10:21 AM |
| Details | Grant Number | Insert | | | H80CS00801 | 5/19/2010 10:21 AM |
| Details | 340B ID | Insert | | | CH08013D | 5/19/2010 10:21 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 5/19/2010 10:21 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 5/19/2010 10:21 AM |
| Details | Medicare Provider Number | Insert | | | | 5/19/2010 10:21 AM |
| Details | Entity Name | Insert | | | PLAN DE SALUD DEL VALLE, INC. | 5/19/2010 10:21 AM |
| Details | Program Code | Insert | | | CH | 5/19/2010 10:21 AM |
| Details | Entity Subname | Insert | | | SALUD FAMILY HEALTH CENTERS - ESTES PARK | 5/19/2010 10:21 AM |
| Dates | Participating Approval Date | Insert | | | 5/12/2010 12:00:00 AM | 5/19/2010 10:21 AM |
| Details | State | Insert | | | Active | 5/19/2010 10:21 AM |
| Dates | Registration Date | Insert | | | 5/12/2010 12:00:00 AM | 5/19/2010 10:21 AM |
| Dates | Signed By Date | Insert | | | 3/23/2010 12:00:00 AM | 5/19/2010 10:21 AM |
| Dates | Start Date | Insert | | | 7/1/2010 12:00:00 AM | 5/19/2010 10:21 AM |
| Terminations | Termination Comments | Insert | | | | 5/19/2010 10:21 AM |
| Terminations | Termination Date | Insert | | | | 5/19/2010 10:21 AM |
| Terminations | Termination Effective Date | Insert | | | | 5/19/2010 10:21 AM |
| Terminations | Termination Reason | Insert | | | | 5/19/2010 10:21 AM |