Provider Demographics
NPI:1164896197
Name:SHADOW MOUNTAIN LLC.
Entity Type:Organization
Organization Name:SHADOW MOUNTAIN LLC.
Other - Org Name:SHADOW MOUNTAIN RECOVERY, UNIVERSITY PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLUB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-389-8591
Mailing Address - Street 1:PO BOX 830525
Mailing Address - Street 2:DPEARTMENT # SF 59
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35283-0525
Mailing Address - Country:US
Mailing Address - Phone:931-451-7757
Mailing Address - Fax:931-933-7762
Practice Address - Street 1:2102 UNIVERSITY PARK BLVD.
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918
Practice Address - Country:US
Practice Address - Phone:719-266-8876
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-13
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility