Provider Demographics
NPI:1154446383
Name:MOUNTAIN SHADOWS SUPPORT GROUP, INC
Entity Type:Organization
Organization Name:MOUNTAIN SHADOWS SUPPORT GROUP, INC
Other - Org Name:SPECIAL KIDS HOMES-MIRAMAR HOUSE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LUPE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-743-3714
Mailing Address - Street 1:2067 W EL NORTE PKWY
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-1810
Mailing Address - Country:US
Mailing Address - Phone:760-743-3714
Mailing Address - Fax:760-736-4173
Practice Address - Street 1:8266 MIRAMAR CIR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92509-4056
Practice Address - Country:US
Practice Address - Phone:760-743-3714
Practice Address - Fax:760-736-4173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46989489313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC80063FMedicaid
CALTC80063GMedicaid