Covered Entity Details

DSH060008Q SAN LUIS VALLEY REGIONAL MEDICAL CENTER (Active) - information as of 5/7/2025 10:45:47 PM

Main Details

Name

SAN LUIS VALLEY REGIONAL MEDICAL CENTER

Subdivision Name

SLV Stuart Avenue Clinic / Regional Occupational Medicine Program

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH060008Q

Medicare Provider Number

060008

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/10/2017

Participating Start Date

4/1/2017

Participating Approval Date

2/22/2017

Last Recertification Date

8/27/2024

Contacts

Authorizing Official

San Luis Valley Regional Medical Center
Konnie Martin, CEO
(719) 587-1202

Primary Contact

San Luis Valley Health
Thomas Robert Wisniewski, Director of Pharmacy
(719) 587-1261

Addresses

Street Address

2115 Stuart Avenue
Alamosa, CO 81101

Billing Address

San Luis Valley Regional Medical Center
106 Blanca Avenue
Alamosa, CO 81101

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
NM	000A1007	1083012504,1235181744,1609003250,1720269434,1821057860,1942511019,1972556744
CO	9000146711,68085770,93388560,24224863,9000144694,11777869,05008008	1235181744,1720269434,1609003250,1821057860,1942511019,1083012504,1972556744

Shipping Addresses

Shipping Address 1

San Luis Valley Regional Medical Center
106 Blanca Avenue
Alamosa, CO 81101

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH060008AA	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV-Health Monte Vista Community Clinic/ OB/GYN - OB/GYN	103 Chico Court	Monte Vista	CO	Active
DSH060008AB	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Regional Medical Center Clinic/ Infusion - Infusion	106 Blanca Ave	Alamosa	CO	Active
DSH060008B	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV-Health Monte Vista Community Clinic	103 Chico Court	Monte Vista	CO	Active
DSH060008C	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Health Stuart Avenue Clinic / Orthopedics	2115 Stuart Avenue	Alamosa	CO	Active
DSH060008D	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Health RMC Clinic / OB/GYN	106 Blanca Avenue	Alamosa	CO	Active
DSH060008E	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Health RMC Clinic / General Surgery	106 Blanca Avenue	Alamosa	CO	Active
DSH060008F	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Health Stuart Avenue Clinic/ Family Practice Primary Care	2115 Stuart Avenue	Alamosa	CO	Terminated
DSH060008G	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Health RMC Clinic / Ear, Nose and Throat	2115 Stuart Ave	Alamosa	CO	Active
DSH060008H	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Health Stuart Avenue Clinic / Chiropractic	2115 Stuart Avenue	Alamosa	CO	Active
DSH060008J	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Health Stuart Avenue Clinic / Behavioral Health	2115 Stuart Avenue	Alamosa	CO	Active
DSH060008K	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Pediatrics Clinic	106 Blanca Avenue	Alamosa	CO	Active
DSH060008L	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Health Stuart Avenue Clinic / Internal Medicine Primary Care	2115 Stuart Avenue	Alamosa	CO	Terminated
DSH060008M	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Oncology Clinic	106 Blanca Ave	Alamosa	CO	Active
DSH060008N	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Regional Medical Center Clinic / Cardiology	106 Blanca Avenue	Alamosa	CO	Active
DSH060008P	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Health Ambulance Service	106 Blanca Avenue	Alamosa	CO	Terminated
DSH060008Q	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Stuart Avenue Clinic / Regional Occupational Medicine Program	2115 Stuart Avenue	Alamosa	CO	Active
DSH060008R	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Health Antonito Rural Health Clinic	115 Main Street	Antonito	CO	Active
DSH060008S	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Health La Jara Rural Health Clinic	509 Main Street	La Jara	CO	Active
DSH060008T	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Health Stuart Avenue Clinic / Urology - Urology	2115 Stuart Avenue	Alamosa	CO	Active
DSH060008U	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Health RMC Clinic / Wound Care - Wound Care	106 Blanca Avenue	Alamosa	CO	Active
DSH060008V	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Health Stuart Avenue Clinic / Primary Care - Primary Care	2115 Stuart Avenue	Alamosa	CO	Active
DSH060008W	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Health La Jara Rural Health Clinic/ OB/GYN - OB/GYN	509 Main Street	La Jara	CO	Terminated
DSH060008X	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV Health Stuart Avenue Clinic/ Coumadin Clinic - Coumadin	2115 Stuart Avenue	Alamosa	CO	Active
DSH060008Y	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV-Health Monte Vista Community Clinic/ Pediatrics - Pediatrics	103 Chico Court	Monte Vista	CO	Terminated
DSH060008Z	Child	DSH	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	SLV-Health Monte Vista Community Clinic/ Neurology - Neurology	103 Chico Court	Monte Vista	CO	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/22/2023 3:37:01 PM	8/27/2024 10:33:04 AM	8/27/2024 10:33 AM
Details	Last Recertification Date	Update	Recertification	9/9/2022 2:50:48 PM	8/22/2023 3:37:01 PM	8/22/2023 3:37 PM
Contacts	Primary Contact	Update	PC Change Request	Spencer, Sadie Director of Pharmacy San Luis Valley Regional Medical Center 7195871261	Wisniewski, Thomas Robert Director of Pharmacy San Luis Valley Health 7195871261	7/20/2023 8:15 AM
Details	Last Recertification Date	Update	Recertification	8/23/2021 4:04:39 PM	9/9/2022 2:50:48 PM	9/9/2022 2:50 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1083012504	8/23/2021 4:04 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/23/2021 4:04 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1235181744	8/23/2021 4:04 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/23/2021 4:04 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1609003250	8/23/2021 4:04 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/23/2021 4:04 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1720269434	8/23/2021 4:04 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/23/2021 4:04 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1821057860	8/23/2021 4:04 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/23/2021 4:04 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1942511019	8/23/2021 4:04 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/23/2021 4:04 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1972556744	8/23/2021 4:04 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/23/2021 4:04 PM
Details	Last Recertification Date	Update	Recertification	8/21/2020 12:55:30 PM	8/23/2021 4:04:39 PM	8/23/2021 4:04 PM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/21/2020 12:55 PM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/21/2020 12:55 PM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/21/2020 12:55 PM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/21/2020 12:55 PM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/21/2020 12:55 PM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/21/2020 12:55 PM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/21/2020 12:55 PM
Details	Last Recertification Date	Update	Recertification	9/12/2019 6:27:27 AM	8/21/2020 12:55:30 PM	8/21/2020 12:55 PM
Contacts	Primary Contact	Update	Change Request	Hankins, Lee Pharmacy Director San Luis Valley Reg. Med Ctr 7195871261-1261	Spencer, Sadie Director of Pharmacy San Luis Valley Regional Medical Center 7195871261	8/5/2020 3:00 PM
Addresses	Shipping Address	Insert	Recertification		San Luis Valley Regional Medical Center 106 Blanca Avenue Alamosa, CO 81101	9/12/2019 6:27 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1235181744 (MT)		9/12/2019 6:27 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	209802105 (AR)		9/12/2019 6:27 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	Q033188 (TN)		9/12/2019 6:27 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	23522600 (FL)		9/12/2019 6:27 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	5221669 (NY)		9/12/2019 6:27 AM
Details	Last Recertification Date	Update	Recertification	8/22/2018 9:03:20 AM	9/12/2019 6:27:27 AM	9/12/2019 6:27 AM
Addresses	Billing Address	Insert	Change Request		San Luis Valley Regional Medical Center 106 Blanca Avenue Alamosa, CO 81101	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1235181744	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MT	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000A1007	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NM	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		209802105	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		Q033188	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		23522600	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		5221669	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9000146711	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		68085770	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		93388560	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		24224863	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9000144694	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		11777869	1/14/2019 12:54 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	1/14/2019 12:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1235181744	1/14/2019 12:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720269434	1/14/2019 12:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1609003250	1/14/2019 12:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1821057860	1/14/2019 12:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1942511019	1/14/2019 12:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1083012504	1/14/2019 12:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1972556744	1/14/2019 12:54 PM
Details	Last Recertification Date	Update	Recertification	11/21/2017 5:11:21 PM	8/22/2018 9:03:20 AM	8/22/2018 9:03 AM
Details	Entity Subname	Update	Recertification	Stuart Avenue Clinic / Regional Occupational Medicine Program	SLV Stuart Avenue Clinic / Regional Occupational Medicine Program	8/22/2018 9:03 AM
Details	Entity Name	Update	Recertification	SAN LUIS VALLEY REG MED CENTER	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	11/29/2017 2:10 PM
Details	Last Recertification Date	Update	Recertification		11/21/2017 5:11:21 PM	11/21/2017 5:11 PM
Contacts	Authorizing Official	Update		Martin, Konnie CEO 7195871202	Martin, Konnie CEO San Luis Valley Regional Medical Center 7195871202	10/9/2017 4:08 PM
Contacts	Signed By	Update		Martin, Konnie CEO 7195871202	Martin, Konnie CEO San Luis Valley Regional Medical Center 7195871202	10/9/2017 4:08 PM
Contacts	Primary Contact	Update		Hankins, Lee Pharmacy Director 7195871261-1261	Hankins, Lee Pharmacy Director San Luis Valley Reg. Med Ctr 7195871261-1261	9/29/2017 4:39 PM
Contacts	Authorizing Official	Insert			Martin, Konnie CEO 7195871202	8/9/2017 4:49 PM
Contacts	Signed By	Insert			Martin, Konnie CEO 7195871202	8/9/2017 4:49 PM
Addresses	Main Address	Insert			2115 Stuart Avenue Alamosa, CO 81101	2/22/2017 9:33 AM
Contacts	Primary Contact	Insert			Hankins, Lee Pharmacy Director 7195871261-1261	2/22/2017 9:33 AM
Dates	Participating Approval Date	Update			2/22/2017 12:00:00 AM	2/22/2017 9:32 AM
Details	State	Update		Pending	Active	2/22/2017 9:32 AM
Dates	Start Date	Update			4/1/2017 12:00:00 AM	2/22/2017 9:32 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_74315	DSH060008Q	1/17/2017 1:44 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_74315	1/10/2017 12:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/10/2017 12:26 PM
Medicaid Billing	Medicaid: Number	Insert			05008008	1/10/2017 12:26 PM
Medicaid Billing	Medicaid: State	Insert			CO	1/10/2017 12:26 PM
Details	Last Recertification Date	Insert				1/10/2017 12:26 PM
Details	Grant Number	Insert				1/10/2017 12:26 PM
Details	340B ID	Insert				1/10/2017 12:26 PM
Details	Is Authorizing Official EHB Data	Insert				1/10/2017 12:26 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/10/2017 12:26 PM
Details	Medicare Provider Number	Insert			060008	1/10/2017 12:26 PM
Details	Entity Name	Insert			SAN LUIS VALLEY REG MED CENTER	1/10/2017 12:26 PM
Details	Program Code	Insert			DSH	1/10/2017 12:26 PM
Details	Entity Subname	Insert			Stuart Avenue Clinic / Regional Occupational Medicine Program	1/10/2017 12:26 PM
Dates	Participating Approval Date	Insert				1/10/2017 12:26 PM
Details	State	Insert			Pending	1/10/2017 12:26 PM
Dates	Registration Date	Insert			1/10/2017 12:00:00 AM	1/10/2017 12:26 PM
Dates	Signed By Date	Insert			1/10/2017 12:00:00 AM	1/10/2017 12:26 PM
Dates	Start Date	Insert				1/10/2017 12:26 PM
Terminations	Termination Comments	Insert				1/10/2017 12:26 PM
Terminations	Termination Date	Insert				1/10/2017 12:26 PM
Terminations	Termination Effective Date	Insert				1/10/2017 12:26 PM
Terminations	Termination Reason	Insert				1/10/2017 12:26 PM