Covered Entity Details

DSH060008X SAN LUIS VALLEY REGIONAL MEDICAL CENTER (Active) - information as of 4/27/2025 12:50:55 AM

Main Details

Name

SAN LUIS VALLEY REGIONAL MEDICAL CENTER

Subdivision Name

SLV Health Stuart Avenue Clinic/ Coumadin Clinic - Coumadin

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH060008X

Medicare Provider Number

060008

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/3/2020

Participating Start Date

4/1/2020

Participating Approval Date

2/25/2020

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
A
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	05008008,9000146711,68085770,93388560,24224863,9000144694,11777869	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 3:38:08 PM	8/27/2024 10:34:55 AM	8/27/2024 10:34 AM
Details	Last Recertification Date	Update	Recertification	9/9/2022 2:50:12 PM	8/22/2023 3:38:08 PM	8/22/2023 3:38 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 4:00:50 PM	9/9/2022 2:50:12 PM	9/9/2022 2:50 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1083012504	8/23/2021 4:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/23/2021 4:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1235181744	8/23/2021 4:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/23/2021 4:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1609003250	8/23/2021 4:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/23/2021 4:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1720269434	8/23/2021 4:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/23/2021 4:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1821057860	8/23/2021 4:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/23/2021 4:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1942511019	8/23/2021 4:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/23/2021 4:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1972556744	8/23/2021 4:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/23/2021 4:00 PM
Details	Last Recertification Date	Update	Recertification	8/21/2020 3:18:10 PM	8/23/2021 4:00:50 PM	8/23/2021 4:00 PM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/21/2020 3:18 PM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/21/2020 3:18 PM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/21/2020 3:18 PM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/21/2020 3:18 PM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/21/2020 3:18 PM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/21/2020 3:18 PM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/21/2020 3:18 PM
Details	Last Recertification Date	Update	Recertification		8/21/2020 3:18:10 PM	8/21/2020 3:18 PM
Details	State	Update		Approved	Active	4/1/2020 12:05 AM
Contacts	Signed By	Insert	New Registration		Martin, Konnie CEO San Luis Valley Regional Medical Center 7195871202	2/25/2020 3:37 PM
Details	340B ID	Update	New Registration		DSH060008X	2/25/2020 3:37 PM
Details	Entity Name	Update	New Registration	SAN LUIS VALLEY REG MED CENTER	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	2/25/2020 3:37 PM
Details	Entity Subname	Update	New Registration	SLV Health Stuart Avenue Clinic/ Coumadin Clinic	SLV Health Stuart Avenue Clinic/ Coumadin Clinic - Coumadin	2/25/2020 3:37 PM
Dates	Participating Approval Date	Update	New Registration		2/25/2020 3:37:17 PM	2/25/2020 3:37 PM
Details	State	Update	New Registration	Pending	Approved	2/25/2020 3:37 PM
Dates	Signed By Date	Update	New Registration		1/7/2020 3:07:10 PM	2/25/2020 3:37 PM
Dates	Start Date	Update	New Registration		4/1/2020 12:00:00 AM	2/25/2020 3:37 PM
Addresses	Main Address	Insert	New Registration		2115 Stuart Avenue A Alamosa, CO 81101	1/3/2020 5:25 PM
Addresses	Billing Address	Insert	New Registration		San Luis Valley Regional Medical Center 106 Blanca Avenue Alamosa, CO 81101	1/3/2020 5:25 PM
Addresses	Shipping Address	Insert	New Registration		San Luis Valley Regional Medical Center 106 Blanca Avenue Alamosa, CO 81101	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000A1007	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NM	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		05008008	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		9000146711	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		68085770	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		93388560	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		24224863	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		9000144694	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		11777869	1/3/2020 5:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	1/3/2020 5:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1235181744	1/3/2020 5:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1720269434	1/3/2020 5:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1609003250	1/3/2020 5:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1821057860	1/3/2020 5:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1942511019	1/3/2020 5:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1083012504	1/3/2020 5:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1972556744	1/3/2020 5:25 PM
Contacts	Authorizing Official	Insert	New Registration		Martin, Konnie CEO San Luis Valley Regional Medical Center 7195871202	1/3/2020 5:25 PM
Contacts	Primary Contact	Insert	New Registration		Spencer, Sadie Director of Pharmacy San Luis Valley Regional Medical Center 7195871261	1/3/2020 5:25 PM
Details	Last Recertification Date	Insert	New Registration			1/3/2020 5:25 PM
Details	Grant Number	Insert	New Registration			1/3/2020 5:25 PM
Details	340B ID	Insert	New Registration			1/3/2020 5:25 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/3/2020 5:25 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/3/2020 5:25 PM
Details	Medicare Provider Number	Insert	New Registration		060008	1/3/2020 5:25 PM
Details	Entity Name	Insert	New Registration		SAN LUIS VALLEY REG MED CENTER	1/3/2020 5:25 PM
Details	Program Code	Insert	New Registration		DSH	1/3/2020 5:25 PM
Details	Entity Subname	Insert	New Registration		SLV Health Stuart Avenue Clinic/ Coumadin Clinic	1/3/2020 5:25 PM
Dates	Participating Approval Date	Insert	New Registration			1/3/2020 5:25 PM
Details	State	Insert	New Registration		Pending	1/3/2020 5:25 PM
Dates	Registration Date	Insert	New Registration		1/3/2020 5:25:39 PM	1/3/2020 5:25 PM
Dates	Signed By Date	Insert	New Registration			1/3/2020 5:25 PM
Dates	Start Date	Insert	New Registration			1/3/2020 5:25 PM
Terminations	Termination Comments	Insert	New Registration			1/3/2020 5:25 PM
Terminations	Termination Date	Insert	New Registration			1/3/2020 5:25 PM
Terminations	Termination Effective Date	Insert	New Registration			1/3/2020 5:25 PM
Terminations	Termination Reason	Insert	New Registration			1/3/2020 5:25 PM