Provider Demographics
NPI:1326430711
Name:MOUNTAIN SHADOWS SUPPORT GROUP
Entity Type:Organization
Organization Name:MOUNTAIN SHADOWS SUPPORT GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WADE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-743-3714
Mailing Address - Street 1:970 LOS VALLECITOS BLVD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-1473
Mailing Address - Country:US
Mailing Address - Phone:760-743-3714
Mailing Address - Fax:
Practice Address - Street 1:4880 BROOKHILL TER
Practice Address - Street 2:
Practice Address - City:JURUPA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92509-4047
Practice Address - Country:US
Practice Address - Phone:760-743-3714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility