Provider Demographics
NPI:1285867713
Name:SHADOW MOUNTAIN BEHAVIORAL HEALTH SYSTEM, LLC
Entity Type:Organization
Organization Name:SHADOW MOUNTAIN BEHAVIORAL HEALTH SYSTEM, LLC
Other - Org Name:SHADOW MOUNTAIN BEHAVIORAL HEALTH SYSTEM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:KISTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-492-8200
Mailing Address - Street 1:6262 S SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-4055
Mailing Address - Country:US
Mailing Address - Phone:918-492-8200
Mailing Address - Fax:918-493-3268
Practice Address - Street 1:4012 E 35TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-4528
Practice Address - Country:US
Practice Address - Phone:918-492-8200
Practice Address - Fax:918-493-3268
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PSYCHIATRIC SOLUTIONS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-01
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility