Provider Demographics
NPI:1275174658
Name:SHADOW ROCK CARE SERVICES
Entity Type:Organization
Organization Name:SHADOW ROCK CARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GUARDIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:GANTZ
Authorized Official - Suffix:
Authorized Official - Credentials:NCG
Authorized Official - Phone:575-312-0120
Mailing Address - Street 1:PO BOX 13907
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88013-3907
Mailing Address - Country:US
Mailing Address - Phone:575-288-1969
Mailing Address - Fax:575-532-9539
Practice Address - Street 1:1485 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1181
Practice Address - Country:US
Practice Address - Phone:575-288-1969
Practice Address - Fax:575-532-9539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0000082220OtherNATIONAL CERTIFIED GUARDIAN